Care Coordinator

Job Description

Job Description

POSITION SUMMARY

CareLink NM is a Medicaid-funded care coordination program. CareLink is intended to enhance integration and coordination of primary care, behavioral health care, acute care, and long-term care services for individuals with a serious mental illness diagnosis along with a chronic physical health diagnosis.

CareLink NM services include comprehensive needs assessment and individualized care plan; care coordination; prevention, health promotion, and disease management; comprehensive transitional care; individual and family support service; and referrals to community and social support services.

RESPONSIBILITIES

• Carry a minimum caseload of 80 individuals at a time.
• Complete a monthly billable encounter with at least 90% of assigned caseload.
• Contact eligible individuals to provide education and orientation about CareLink services and obtain and document the individuals’ decisions about opting-in to CareLink.
• Conduct Comprehensive Needs Assessment (CNA).
• Create an integrated service plan based on the CNA with the enrolled individual.
• Create crisis and disaster plans with enrolled individuals.
• Conduct a minimum of one encounter per month per client that supports the individual’s progress towards service plan goals.
• Perform all care coordination activities as needed.
• Maintain clear, concise, and timely documentation adhering to all policies and procedures.
• Document client interactions and encounters in the GCLC electronic health record, the State of New Mexico’s NMSTAR system, and internal spreadsheets.
• Maintain all client charts following the CareLink Policy Manual and GCLC requirements.
• Function as the hub for the individual’s care team developed in collaboration with the individual, their natural supports, and as informed by the CNA.
• Engage natural supports and community resources to assist in overcoming barriers to engagement or access to care.
• Engage and collaborate with all integrated care team members and conduct team meetings as necessary to make sure client’s medical and mental health needs are understood by all team members.
• Understand and maintain HIPAA and 42CFR Part 2 confidentiality standards.
• Participate in all mental health department training and supervision.
• Be proficient in all aspects of the CareLink Policy Manual and additional program-related requirements.
• Perform other duties as assigned.

QUALIFICATIONS

Minimum

With two years of relevant experience in behavioral healthcare; or

Respond all emails and correspondence (voice messages, telephone encounters and messages).

Preferred