Job Purpose: The primary responsibilities of the Transitional Care Team Care Coordinator (TCT CC) are to provide support to the team lead, nurse, and social worker in the holistic multi-disciplinary team approach, which includes social and emotional assessment, planning, facilitating, education and advocacy for the treatment model protocols that will enhance the quality of life for individuals receiving services.
Essential Job Functions:
1. Communicate effectively with individuals receiving services, providers, and other members of the Transitional Care Team Outreach with multicultural and diverse socioeconomic backgrounds under the supervision of the Team Leader.
2. Conduct face-to-face encounters with individuals receiving services in the hospital clinical setting, at providers offices, and in various other community settings, in regards to identifying barriers that prevent the individuals receiving services from securing appropriate Behavioral Health and Primary Care in the community.
3. Make appropriate referrals to community resources and empowers individuals to be responsible for their own healthcare and personal needs.
4. Review data to identify and determine appropriateness for care management, which includes monitoring utilization, reporting, and compliance issues.
5. Develop, monitor and evaluate, with members of the team, plans of care for the individuals receiving services that require coordination of care from various providers in the community, through ongoing review of medical records, telephone contact, home visits, community encounters, consultation with Behavioral Health and Medical Providers
6. Encourage, Empower and Educate individuals receiving services to the self-responsibilities of chronic disease management utilizing provided self-management tools and approved best practice models.
7. Maintain current and ongoing records in the Electronic Health Record (EHR).
8. Meet regularly with the other TCT members to formulate and disseminate information and be available by telephone and/or pager.
9. Reach out to individuals with recent ED utilization within 24 business hours of notification.
10. Provide case management services with guidance and collaboration from all service providers
11. Attend and actively participate in meetings and training as required. Maintain certification in all agency, state and federal training requirements.
12. Demonstrate knowledge of and comply with all agency policies and procedures, as well as state and federal statutes and regulations related to specific program areas.
13. Work autonomously and utilize functional time management skills to meet program needs.
14. Follow service definition guidelines for services provide that are managed by state and/or federal regulations.
15. Complete all other relevant responsibilities as assigned by the supervisor.
16. Driving and travel may be required.
1. Master's degree in a human service field and one year of mental health, developmental disabilities and substance use experience with the population served, or one year of full time supervised experience in alcoholism and drug abuse counseling OR
2. Bachelor's degree in a human service field and two years of mental health, developmental disabilities and substance use experience with the population served, or two years of full time supervised experience in alcoholism and drug abuse counseling OR
3. Bachelor's degree in a field other than human services and four years of mental health, developmental disabilities and substance use experience with the population served, or four years of full-time supervised experience in alcoholism and drug abuse counseling OR
4. Registered Nurse licensed to practice in the State of North Carolina by the North Carolina Board of Nursing with four years of full-time experience in mental health, developmental disabilities and substance use with the population served.
5. Valid North Carolina Driver License.
Job Type: Full-time