Integrated Services Care Coordinator

Description

JOB SUMMARY: Responsible for the overall care coordination, including SUD, medical, mental health and other behavioral health services. 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:

1. Assist new patients in completing paperwork and releases of information needed to transfer medical care.
2. Act as the system navigator and point of contact for patients and families. 
3. 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).
4. 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.
5. Schedule appointments with external medical specialists, as requested by the medical team and explain purpose of appointments in clear and simple language.
6. 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.
7. 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.
8. 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.
9. 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.
10. Use a step-by-step process when teaching skills, use positive reinforcement and encouragement and use a flexible approach with a diverse population.
11. Attend both mandatory in-service trainings and related conferences and provide feedback to staff on the content of educational programs attended.
12. 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.
13. Advocate on the patient’s behalf to ensure approval of the necessary supplies/services for the patient in a timely fashion.
14. Complete notes for all care coordination services; progress notes as needed and required interagency paperwork.
15. Distribute and collect outcome surveys.
16. Seek opportunities to improve outcomes through population health management.
17. Other duties as assigned

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.  

1. Time Management – Maximizes the use of time and resources and effectively prioritizes tasks. Completes paperwork, evaluations, and other required documentation accurately and timely.
2. 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.
3. Flexibility – Adapts rapidly to changing work demands and priorities.
4. 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
5. Safety – Knows and understands emergency procedures and completes incident reports within 24 hours of event with detailed information.
6. 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.
7. 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 boundarie