The Care Coordinator operates under the FLC Health Home Care Coordination Organization and FLC Health Home Lead. The Care Coordinator directly interacts with Health Home service beneficiaries and is responsible for the conversion of beneficiaries from outreach to engaged. Care Coordinator works with beneficiary to develop a Health Action Plan that includes a client-driven long-term goal, coinciding short-term goals and specific action steps as well as required and clinically indicated screenings. The Care Coordinator is responsible for supporting beneficiaries and their families in coordinating the beneficiary’s healthcare services and increasing the beneficiary’s and family’s knowledge and skills to be able to self-manage healthcare needs. The Care Coordinator provides six Health Home services to beneficiaries on caseload as appropriate and needed. These services include comprehensive care management, care coordination and health promotion, transitional care planning and follow-up services, individual and family education and collaboration, community and social support services referral coordination, and use of health information technology. The Care Coordinator will communicate with authorizing entities and the beneficiary’s interdisciplinary team to ensure quality and continuity of care according to beneficiary’s goals. The Care Coordinator will provide services in the community where the beneficiary resides and services will be provided in-person when needed at the location of beneficiary’s request. The role of the Care Coordinator involves direct coordination, advocacy, and education to assist the beneficiary in understanding the healthcare system and to access services for physical and behavioral health needs.
Essential Position Functions:
- Coordinates and oversees Health Home benefit services by actively engaging beneficiary via completion of Health Action Plan and supporting the beneficiary to achieve their short and long-term goals. Responsible to maintain adequate number of beneficiaries currently outreaching to, necessary to maintain a caseload of 55.
- Meets with beneficiary on monthly basis and/or actively assisting and coaching beneficiary on action steps related to long and short-term goals. Actively seeks necessary support if challenges incur meeting the monthly encounter expectation with each client. Expectation is that care coordinators are incurring a billable monthly encounter with 95% of their caseload.
- Serves as connecting point between and across beneficiary’s medical and direct care providers as well as informal family and community supports per beneficiary’s consent.
- Increase the utilization of preventative care by assisting with facilitation of referrals for clinically indicated services and supports including primary care and behavioral health that are related to beneficiary’s Health Action Plan goals.
- Reduce emergency room utilization and hospital readmissions.
- Utilizes health technology to connect beneficiary with needed services and to close feedback loop with various providers on beneficiary’s care team.
- Assist beneficiaries, family members and other informal supports with concern and empathy; respect their confidentiality and privacy and communicate in a courteous and responsive manner.
- Answer and refer telephone calls and emails or other inquires to ensure timely and accurate communications are facilitated regarding beneficiaries health care and wraparound services.
- Conduct facility, community, and client-centered outreach to engage eligible and interested beneficiaries in Health Home services and educate community partners about Health Home services.
- Manage caseload of 55 clients (FTE caseload) to assure quality and timely services are provided to each beneficiary engaged in Health Home services. Takes initiative with managing needs of caseload and maintaining day-to-day schedule and consults with supervisor and care team as needed.
- Responds to individual cases per Health Home scope of services; e.g. follow-up with beneficiary in the hospital prior to discharge or within two days of discharge in the event beneficiary is hospitalized.
- Review Health Action Plan every four months with each beneficiary to maintain eligibility for services.
Marginal Functions of the Position:
- Complete projects and tasks as assigned by supervisor;
- The ability to prioritize projects needing to be completed in a timely manner;
- Collaborate with and train staff on proper operation and maintenance of program systems and equipment;
- Availability to be reached and respond quickly to facility emergencies.
- Must have excellent verbal and written communication skills;
- Must have access to private reliable means of transportation; may require reliable vehicle for client transport;
- Current Washington State Driver’s License and proof of safe driving record obtained through appropriate Washington state department;
- A Bachelor’s Degree or higher in Social Work, Psychology, or related field with relevant professional experience;
- Ability to effectively use computer and communication technology;
- Able to work independently and communicate effectively with clients and supervisors.
- Ability to work in fast-paced environment and daily prioritize and complete tasks.
- Ability to maintain professional boundaries and practice self-care.
- Dependable and responsible;
- Likes people and has a nurturing and caring attitude;
- Organized, self-motivated, honest, and mature;
- Must be able to lift 25lbs and support client’s mobility;
- Must be able to operate office equipment including but not limited to computer keyboards, multi-line phone system, fax and copy machines.