TRC - Health Homes Services - Care Coordinator - Part Time

CARE COORDINATOR - Job Description  RESPONSIBLE TO: Health Homes Manager  FUNCTION: The Care Coordinator serves as a member of an interdisciplinary team who coordinates service provision for a caseload of clients that may have a severe mental illness with multiple medical co-morbidities, co-occurring substance abuse disorders, and/or a variety of medical complexities. This is a “medium touch” position with an assigned caseload ratio of 1:50 clients. Advocates for and supports the client, engages with community agencies/health care providers and others on their behalf to ensure access to services needed to increase wellness, self-management, and reduce emergency room visits/hospitalizations. Provides clinical support to the team by providing consultation, education, information pertaining to psychosocial and/or substance abuse conditions, interventions, and resources to maintain focus on outcomes and best practices.  SPECIFIC DUTIES:1. Conducts initial and ongoing assessments of assigned clients to document strengths, needs, goals, and resources. 2. Participates in the development, documentation, review, and update of client-centered comprehensive, integrated, and interdisciplinary care plans, in conjunction with other team members to ensure focus on desired outcomes. 3. Maintains effective communications with clients, primary care physicians, substance abuse and mental healthcare providers, family, collateral resources and other Agency staff on behalf of clients. 4. Maintains documents, records, statistics, and other related reports in an organized, timely, and accurate manner as per policy and procedure. 5. Coordinates care planning with other providers of services/resources to ensure goal-directed, collaborative care, including care transitions. 6. Works as part of a Care Coordination team; attends and participates in team meetings to provide input/feedback around psychosocial and medical conditions/co-morbidities to review client status, update plans/goals, and review outcomes to further program goals. 7. Serves as a resource/consultant/mentor to Care Coordination Specialists on psychosocial, medical and/or substance abuse issues and resources under the guidance of Clinical Care Coordinator. 8. Provides telephonic as well as face-to-face outreach, engagement, and service planning in the field. 9. Provides linkage to community services including medical, behavioral, residential, entitlement and any other needed services per interdisciplinary care plan. 10. Monitors overall service delivery to clients to ensure coordination and continuity; advocates with service providers/resources as needed. 11. Provides crisis intervention and follow-up. 12. Attends Single Point of Access Meetings (SPOA) to represent program, as well as other community meetings to assist in marketing or connecting potential clients to services. 13. Provides self-help educational groups to clients. 14. Performs all other related duties as needed or assigned.  REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: Must possess strong organizational skills and abilities in order to meet the multi-faceted needs of clients in a timely manner; Must possess an understanding of all applicable state and federal regulations related to health homes and a current working knowledge of social work best-practices; Must possess strong analytical skills to assess baseline progress and revise/establish goals/outcomes; Experience with individuals with disabilities and knowledge of rehabilitation and counseling services is essential; Comprehensive understanding of guiding principles of rehabilitation and counseling is critical; Must be self-directed and able to initiate and manage multiple responsibilities effectively and efficiently; Excellent verbal and written communication skills across various channels is paramount; Must be flexible and willing to work non-traditional hours as needed or assigned to meet client need; Physical condition commensurate with the demands of the job. MINIMUM QUALIFICATIONS: Bachelor’s degree in Social Work, Human Services, Nursing, or related field plus two (1) year of experience in care coordination, case management or related field. Experience with mental health, substance abuse, or medical frailties are strongly preferred. Valid driver’s license, use of personal vehicle, and willingness to travel for work is required. Bilingual stipend available for hired staff that meet criteria . Travel throughout Chautauqua county required with work available between multiple office sites. 9/2013 Social Services THE RESOURCE CENTER Non-Graded Range, Non-exempt

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