Care Coordinator
Current1. Conduct outreach activities and engage individuals with chronic medical conditions, mental health issues, and/or substance use disorders, often co-occurring.2. Conduct initial and ongoing comprehensive assessments to determine strengths and identified needs.3. Prepare and revise care plans to reflect client needs and personal goals with a focus on maintaining health and wellness.4. Maintain contact with clients at least monthly, providing telephonic as well as face to face outreach, engagement, and comprehensive service planning in the field.5. Advocate for and support clients to ensure access to resources necessary to support wellness/self-management and decrease frequency of emergency room visits and inpatient hospital admissions.6. Monitor and coordinate all care for clients, including access and maintenance of medical insurance, linkage to treatment providers and community resources.7. Collaborate with community providers at least monthly as part of a multi-disciplinary team to ensure goal-directed care planning.8. Conduct crisis intervention when needed and follow up accordingly.9. Maintain detailed, timely, and accurate record keeping in an electronic medical record. Coordinate with supervisor and health home outreach team in a timely manner to ensure accurate caseload status (including enrollments, closures, and screen outs).10. Complete all required monthly documentation as required to ensure continuity of engaged clients’ medical insurance and to ensure appropriate and accurate billing.11. Offer resources and serve as a consultant to all team members on medical/psycho-social/substance use issues as well as social service needs.