Care Coordinator 1 HW

SUMMARY Under the direct supervision of the CCS Supervisor, the Care Coordinator 1 performs general functions as a liaison between the patient and their family or community members and both primary care and behavior health services.  The Care Coordinator 1 is responsible for ensuring appropriate delivery of services and coordinating care within health and behavioral health network and with external entities collaborating on patient care.  The Care Coordinator 1 provides excellent quality care, positive customer service, the maintenance of an efficient and safe environment of care. Demonstrates superior customer service skills and has the ability to function in a multi-tasking, multiple priorities environment, while maintaining accuracy and attention to detail.

ESSENTIAL DUTIES AND RESPONSIBILITIES 

• Maintain patient confidentiality at all times per the policies and procedures.
• Maintain ethical behavior at all time per the policies and procedures.
• Responds to internal and external customer needs in a positive manner, utilizing principles of the AIDET model; exceeding their needs and expectations and providing the highest quality service to ensure the best possible outcomes.
• Manages caseload to ensure behavioral health needs are managed.
• Ensure patients receive medical, dental and behavior health appointments.  
• Monthly in- person contact once a month, telephonic contact three times a month and family team meetings occur at least once every two months.     
• Develop a working care plan in collaboration with of patient, primary care provider, behavior health provider and family. 
• Manage various databases while appropriately documenting patient data and information within the various portals. 
• Function as a liaison between behavior health and primary care by participating in all related patient care team meetings, case consultation and clinic huddles. 
• Knowledge and understanding medical and mental health conditions and impact to the patient. 
• Complete necessary assessments including but not limited to evidence-based screening tools (i.e., SBIRT, PHQ-2 /PHQ-9, GAD7, Vanderbilt, etc.).
• Provide patients with case management to include, but not limited to providing internal and external referrals for mental health, substance abuse, or community resources and patient advocacy.  
• Collaborate with health plans, specialists, hospitals, and physicians to ensure complete and total patient care.
• Attend all trainings and meetings as required by the program. 
• Complete all Core Curriculum training(s) required for this position.
• Perform all other duties as assigned.

KEY COMPETENCIES:

• Dependable and reliable giving extra effort when necessary to accomplish Aunt Martha’s Health & Wellness goals.
• Takes initiative to proactively recognize problems/opportunities and develop appropriate strategies to deal with them.
• Ability to manage multiple and competing demands and establish priorities. Ability to learn quickly and adapt to change in processes and organization.
• Makes data driven supported decisions wherever possible considering all relevant facts.
• Ability to work independently and as part of a collaborative team in order to meet health division goals and priorities. Acts cooperatively and contributes to teamwork. Willingness to act as a strong team player and bring an optimistic level of energy to the team.
• Maintains professional, technical and technological proficiency in all aspects of the job.
• Excellent oral and written skills. Communicates decisions promptly, clearly.
• Excellent organizational skills and attention to detail, deadlines and program compliance. 

QUALIFICATIONS  

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

EDUCATION and/or EXPERIENCE 

• BA in social work, psychology or related field with 1 year experience working with in behavior health field or related field preferred 

• Experience in working with Microsoft Office programs and data base management essential; adept at data entry 

LANGUAGE SKILLS 

Ability to speak, read and write English. Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.  Ability to write routine reports and correspondence.   Ability to speak effectively before groups of customers or employees of organization. Bilingual skills (English/Spanish) a plus

MATHEMATICAL SKILLS 

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.  Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

REASONING ABILITY           

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

PERFORMANCE IMPROVEMENT  

Ability to understand and demonstrate Aunt Martha's 4-step Performance Improvement process, utilizing the methodology Plan, Do, Study, Act (PDSA).

JOB KNOWLEDGE 

Ability to use technical skills and apply knowledge necessary for this position.

QUALITY  

Ability to demonstrate accuracy and thoroughness while performing the duties of this position.

SAFETY AND INFECTION CONTROL  

Be knowledgeable about and follow Aunt Martha's safety policies and procedures.

OTHER QUALIFICATIONS

Current driver’s license 

Current auto insurance

Ability to work late evening hours, weekend hours, and scheduled holidays, as needed

PHYSICAL DEMANDS  

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear.  The employee frequently is required to stand and walk.  The employee is occasionally required to climb or balance; stoop, kneel, crouch, or crawl; and taste or smell.  The employee must occasionally lift and/or move up to 10 pounds.   Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  

While in the clinic, there may be some exposure to communicable disease, body fluids, toxic substances, medicinal preparations, radiation and other conditions common to a clinical environment. The noise level in the work environment is usually moderate.

ORGANIZATION-WIDE EXPECTATIONS: 

• All employees are expected to adhere to Aunt Martha’s mission, vision and guiding principles.  
• All employees are expected to adhere to all Agency and Division/Department policies and procedures.
• All employees are expected to maintain all required competencies, registrations; certifications, licenses and personnel file documentation as required by the agency, funders and/or accrediting bodies.
• All employees are expected to embrace diversity, treat our patients and co-workers with dignity, respect, and hold others to these standards.
• All employees are expected to uphold the confidentiality requirements of all patient records consistent with HIPPA, State, and Federal laws and regulations