Integrated Care Coordinator

Description

JOB SUMMARY: Responsible for the overall care coordination, including SUD, medical, mental health and other behavioral health services for patients who are referred or identified as candidates for the Behavioral Health Home Program. Offer a holistic, whole-person approach to care. Assures adherence to state statutes and rules, CARF standards, and federal regulations including HIPAA and 42 CFR Part 2. Positively represents the organization and promotes Rimrock’s Mission to the community.

Essential Functions

• Identify and engage health home care coordination patients at Rimrock who have at least two chronic health conditions, such as “asthma, diabetes, heart disease, obesity, mental condition, and substance abuse disorder or one chronic condition and be at risk for another; or one serious and persistent mental health condition.
• Assist new patients in completing paperwork and releases of information needed to transfer medical care.
• Act as the system navigator and point of contact for patients and families.
• Assist patients and their families in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance).
• Assist patients during their medical appointment and provide as-needed education in order to assist in the understanding of disease, medication compliance, recommended specialty services and/or any other medical needs.
• Schedule appointments with external medical specialists, as requested by the medical team and explain purpose of appointments in clear and simple language.
• Participate as a member of a multi-disciplinary team including but not limited to both medical and psychiatric members towards the development and management of operations of health home services.
• Coordinate with Rimrock team and community services as needed to ensure that both current diseases, as well as preventative and health promotion needs are addressed.
• Teach and assist patients to gain the skills necessary to self-manage chronic diseases using realistic and SMART (specific, measurable, attainable, realistic and timely) goals.
• Assist consumers with budgeting and money management as it relates to their medical needs; refer to lead case manager at Rimrock if there is case management already involved.
• Use a step-by-step process when teaching skills, use positive reinforcement and encouragement and use a flexible approach with a diverse population.
• Attend both mandatory in-service trainings and related conferences and provide feedback to staff on the content of educational programs attended.
• Negotiate on behalf of the patient, as needed, with the medical and psychiatric treatment team, and patients themselves by creating reasonable goals, clarifying the issues to be negotiated, following through with the agreement reached, while remaining flexible and consider culturally sensitive and holistic alternatives.
• Advocate on the patient’s behalf to ensure approval of the necessary supplies/services for the patient in a timely fashion.
• Complete notes for all care coordination services; progress notes as needed and required interagency paperwork.
• Distribute and collect outcome surveys.
• Compute, organize and develop outcome surveys and develop presentation on information and assist in presenting.
• Seek opportunities to improve outcomes through population health management.
  
  

Organizational Competencies

• Accountability – Takes ownership for resolving problems, reaching goals, and serving patients, team, and organization. Accepts responsibility for own behavior. Assures that resources are allocated in accordance with the priorities of the strategic plan. Performs self-quality monitoring in order to develop and execute plans to meet established goals.
• Time Management – Maximizes the use of time and resources and effectively prioritizes tasks. Completes paperwork, evaluations, and other required documentation accurately and timely.
• Teamwork – Works cooperatively and capably with a wide variety of people. Actively promotes teamwork and information sharing within and across departments. Works in a spirit of teamwork and trust and maintains professional boundaries in working with others.
• Flexibility – Adapts rapidly to changing work demands and priorities.
• Confidentiality – Complies with all HIPAA and 42 C.F.R. Part 2 regulations relating to privacy, security, and confidentiality. Safeguards confidential information of patients, employees, and business operations
• Safety – Knows and understands emergency procedures and completes incident reports within 24 hours of event with detailed information.
• Communication – Consistently uses positive communication skills to promote effective interpersonal relationships. Provides timely and thorough follow-up with internal and external customers. Models professionalism by addressing others with appropriate actions, appearance, and communication. Models and promotes effective written and verbal communication.
• Customer Service – Supports the organization’s customer service initiative. Strives for service excellence by seeking challenges and turning them into opportunities. Anticipates and meets needs of patients while maintaining appropriate boundaries. Displays a friendly, helpful, and approachable demeanor. Obtains feedback from patients regarding their perceptions of the service provided to them and utilizes this information to improve service delivery.
• Respect – Establishes compassionate and supportive rapport with patients. Communicates tactfully and respectfully with patients, coworkers, and others.
• Quality Improvement – Assures that information is collected, organized, reported and used to improve the quality of systems and services. Recognizes and appropriately reports to supervisor areas within scope of responsibility that fall outside the quality parameters. Serves on committees or process improvement teams to assist in improving quality/customer satisfaction, as assigned.
  
  

EDUCATION/TRAINING: Must have High School Diploma or GED. Experience with the psychiatric population preferred.

CERTIFICATE OR LICENSE: Must have valid driver’s license and insured automobile.

SKILLS: Communication, ability to give direction and work adjunctively with therapeutic team, provide empathy and possess knowledge of adolescent patients with addictions, implement positive reinforcement of patients and ability to stay organized. Clinical supervision and therapeutic skills. Computer skills and proficiency with Microsoft software including Word, Excel and Outlook.

PHYSICAL DEMANDS: Work is indoors in an office environment with moderate noise. Intermittent physical effort involving lifting of up to 25 pounds, walking and stooping is required. A typical workday involves sitting, frequent use of a keyboard, reaching with hands and arms, and talking and hearing, approximately 70% of the time. Approximately 30% or less of the time is spent standing. Normal vision abilities required, including close vision and ability to adjust focus.

WORK ENVIRONMENT/JOB LOCATIONS: Involves everyday risk or discomfort requiring normal safety precautions in the Medical Unit. Work may involve mental and emotional stress. Some driving required. Will work primarily in main facility.

Disclaimer: The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of responsibilities, duties and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.