Health Homes Care Coordinator- Spokane County

 Who we are

Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.

Our commitment is to:

• Strive to apply an equity lens to all our work. 
• Reduce health disparities. 
• Become an anti-racist organization 
• Create an equitable work environment. 

About the Role

The primary responsibility of the Health Home Care Coordinator is to work with enrolled members to develop and implement Health Action Plans (HAPs) that move members along a pathway to improved quality of life, health, and engagement. The coordinator will work with members over time to seek and use resources that match the members’ needs and provide the six Health Home services of comprehensive care management, care coordination, health promotion, individual and family support, care transitions, and referrals to community and social support services. This position is field based.

To be successful in this role, you:

• Possess current license as registered nurses, practical nurses, mental health counselors; and/or
• Master’s or bachelor’s in social work, psychology, social services, human services, and behavioral sciences.
• Possess current WA state driver’s license required.
• Have at least two (2) years of related experience in social services, health care or case management, preferably with fieldwork required.
• Are experienced working with people with mental illness and/or substance use preferred.
• Have two (2) years’ experience with Medicare, Medicaid, and NCQA strongly preferred.
• And two (2) years’ experience working with screening tools, evidenced based techniques, complex and chronic mental illness, and substance abuse strongly preferred.
• Must have reliable transportation, a clean driving record, be able to drive, and have motor vehicle insurance that meets state required minimums.

Essential functions and Roles and Responsibilities:

• Responsible for engaging prospective Health Homes participants who have been identified through referrals received by Health Home Lead to likely benefit from Health Home program offerings.
• Manage a caseload of 50 members by taking initiative with managing the needs of the caseload, scheduling and organizing time
• Conducted telephonic and face-to-face outreach and coordination of care activities for Health Homes members.
• Increase members’ ability for self-management and shared decision-making.
• Coordinate and oversee the Health Home benefit by actively engaging the member via completion of Health Action Plan and supporting the member to achieve their short-term and long-term goals.
• Improve continuity of care by helping members navigate relationships with providers and outside resources.
• Provides follow up services via telephonic or face-to-face engagement with members and service planning partners as needed to coordinate reminder calls, medications, and medical appointments.
• Provides community outreach services including home visits, assisting members with accessing transportation services, educating members on healthy behaviors, and providing information on community resources.
• Provides information to increase the member’s knowledge about their health conditions and improve adherence to prescribed treatment.
• Track meetings with the members monthly and actively assist and coach them to meet their goals and assist them with assessed needs.
• Observes safety and security procedures; determines appropriate action beyond guidelines; reports potentially unsafe conditions.
• Complete required documentation within deadlines.
• Attend on-site internal meetings as required, including 1:1s, department meetings, staff meetings, etc.
• Maintain appropriate confidentiality of all member health information.
• This position requires traveling on behalf of the Company and working in the field at least 50% of the time. It is essential that a current driver’s license, proof of insurance and acceptable driving record be maintained.
• Travel to member location in varied environments required.
• Complete Monthly Billing for services
• Non-Exempt – Employees are expected to report to work as scheduled, participate in all assigned meetings, and meet established performance and accountability standards.
• Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole d