With the support and supervision of the Care Coordination Assistant Director, the Care Coordinator, Complex Care (CCSP) will manage a panel of high-need members (e.g. HARP, AOT, Adult Home, Health Home Plus, high utilizer BH/HIV etc.), providing field-based care coordination. The CCSP is responsible for assessing, care planning, and connecting high need care coordination candidates/members to a variety of community-based services including but not limited to medical, substance use recovery oriented services, mental health services, HCBS, medication management, housing support, transportation, peer support, and other member needs that may arise.
1. Provide daily oversight of an assigned panel of high-need candidates/members, delivering interventions designed to reduce unnecessary emergency department (ED)/emergency room (ER) and inpatient (IP) utilization, increase connection to primary care/behavioral health care, and demonstrate improved health outcomes for the served population. Communicate changes in member’s status (e.g. mental health, medical, social determinants impacting health and wellness) to the care team
2. Provide daily oversight of an assigned panel of candidates/members, delivering interventions designed to reduce unnecessary emergency department (ED)/emergency room (ER) and inpatient (IP) utilization, increase connection to primary care, and demonstrate improved health outcomes for the served population.
3. Administer program requirements as defined by all applicable federal, state, local, and agency guidelines (i.e.,
assessments, care plans, documentation of services, etc.) and other Health Home documentation required to
address member needs.
4. Monitor alerts (i.e., hospital admission/discharge, incarceration, ER/ED visit, etc.) and follow up with members
promptly, verifying appropriate levels of care and access to all needed medications, therapies, and supports in
managing care transitions.
5. Provide regular, field based face-to-face visits with members/candidates in home and/or community settings,
ensuring core services and HML are completed monthly.
6. Participate in case conferences to ensure that each member’s care team is aligned with a shared plan of care and up-to-date information on each member. Provide written status updates on a regular basis as requested (case conference tool, status update tools, emails, etc.) and verify documentation of all such activities in member chart.
7. Adhere to timeframes and quality standards regarding completion of member assessments, reassessments, care plans, and documentation standards including HARP Eligibility Assessment, HARP Plan of CAre, LOSD, etc.)
8.Manage schedule to allow for adequate field time, travel time, and time to complete administrative duties of position.
9. Maintain a directory of provider services including medical, behavioral health, social support and other services as needed to support referral and coordination activities of assigned staff; Identify valuable resources to share with the rest of the team to the benefit of all members.
10. Proactively adhere to policies and procedures; participate in department/agency trainings/workshops as directed.
11. Develop and maintain proficiency as a user of the Electronic Health Record System(s) of the agency; uphold all policy related to use of the system and documentation time frame.
12. Carry a caseload of 20 patients.
13. Willingness and ability to regularly travel between assigned work sites
14. Attend meetings, committees, and trainings as requested and or and other duties as assigned.
KNOWLEDGEABLE IN:
Health Home and Care Coordination Services
