Community Engagement Program Care Coordinator

Job Description

Job Description

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JOB SUMMARY

The Community Engagement Care Coordinator proactively provides a broad array of clerical, case management and clinical coordination for patients with a history of involvement with the misdemeanor courts who are struggling with mental health, substance use and / or homeless or at risk of becoming homeless.

The Care Coordinator is a member of the Integrated Behavioral Health clinical care team and works in continuous partnership with the patient, their family when appropriate, SCHC Health care team, probation, courts, other justice agencies and relevant community partners to improve health outcomes and meet the patient’s desired health and wellness goals. The Behavioral Health Care Coordinator serves as the contact point, advocate, and informational resource for patients, family / caregiver(s), primary care team, payers, and community resources regarding Behavioral Health services; facilitates access to internal and external services; identifies and addresses gaps in care; and increases patient’s ability for self-management and shared decision-making while reducing recidivism.

JOB DUTIES AND RESPONSIBILITIES

• Evaluates social determinants of health, identifies barriers to care and addresses / resolves obstacles impeding progress
• Provides support to help maximize quality measures
• Assist client with meeting the goals identified in their care plan.
• Determines the appropriate level of care coordination needed to support the patient at any given point in time
• Facilitates patient access to appropriate services, both internal and external
• Follows up on no-show patients and fill same day cancellation appointment slots.
• Participates in huddles, team meetings, and case conferencing as needed.
• Educates patient and family / caregiver(s) about relevant community resources
• Acts as point of contact for any behavioral health needs
• Collaborates with general care coordinators to limit overlap and ensure closed-loop BH referrals
• Provides support to behavioral health providers by completing forms and other tasks as needed.
• Administers new and returning patient self-report and satisfaction questionnaires
• Documents timely and efficiently in the EHR
• Attends appropriate training courses / webinars and meetings
• Gathers and reports related to aspects of care coordination monthly
• Provides feedback for the improvement of Care Coordination processes
• Perform other duties as assigned

KNOWLEDGE, SKILLS, AND ABILITIES

EDUCATION & EXPERIENCE

PREFERRED QUALIFICATIONS

BENEFITS

SCHC understands the importance of good health for every employee. We offer a comprehensive benefits package to ensure employees and their families receive the optimal in health care coverage, along with options to meet their needs.