Coordinate the delivery of integrated care services to members by collaborating with clinical staff, community systems, and other stakeholders to address comprehensive treatment needs.
Conduct outreach and engagement efforts in community settings including homeless camps, shelters, emergency departments, jails, detox centers, and other identified locations, with emphasis on high-risk populations such as pregnant individuals, IV drug users, and justice-involved persons.
Perform initial screenings, assessments, urgent engagements, diagnostic evaluations, and annual updates in both community and crisis settings.
Assist members with diversion or stabilization, pre-enrollment services, and linkage to Medication-Assisted Treatment (MAT).
Facilitate intake and enrollment in care by coordinating with internal staff and supporting members throughout the process.
Facilitate care coordination with internal staff for members who are admitted and discharged for identified and allocated community systems and stakeholders.
Provide transportation and accompaniment to medical, behavioral health, legal, and social services appointments as needed.
Conduct integrated healthcare assessments and identify barriers to treatment or health access, making appropriate interventions or referrals.
Support members in following through diagnostic tests, treatment recommendations, and medication adherence, offering education and navigation.
Obtain and file relevant health records and provider notes in the electronic health record while ensuring documentation is complete and timely.
Develop, implement, and revise integrated service plans and monitor progress on treatment goals and crisis plans.
Provide consistent follow-up on referrals and maintain regular contact with treatment teams to track member progress and ensure continuity of care.
Offer individualized education, advocacy, and support through home-based, office-based, and community-based services.
Maintain accurate written records of outreach efforts, enrollment potential, and service delivery.
Assure accurate billing is submitted for each interaction and/or activity supporting a member’s treatment goals.
Perform crisis intervention, de-escalation, and reengagement outreach via various methods including phone, home, and jail visits.
Attend required staff meetings, training, and participate in interdisciplinary case conferences.
Support other departments in service engagement efforts and contribute to continuous program development.
Coordination of 24/7 hour lines and support of after-hours responsibilities
Perform additional duties in line with agency growth and evolving service needs
