The Native American Health Center is an accredited institution and adheres to the standards of excellence set forth by the Accreditation Association of Ambulatory Health Care (AAAHC) and the Commission of Dental Accreditation (CODA).
POSITION SUMMARY
The Care Coordinator functions as a member of an integrated system of care team who will work with providers across NAHC and other systems of care to provide NAHC clients with access to an integrated, holistic system of care. The Care Coordinator will provide care coordination, case management, member navigation, system navigation (internal and external), peer advocacy, health education, mapping individual, family and community supports and assets, panel management support, home visits (when appropriate), and warm handoff services. The Care Coordinator may work with other mental health providers when such treatment is indicated. The care coordinator may provide report writing, when appropriate. The Care Coordinator III will provide supervision to the CCIs and CCIIs.
DUTIES AND RESPONSIBILITIES
Care Coordination Management
1. Manage, supervise, and represent NAHC’s Care Coordination services and staff with the support of the IBH Manager.
2. Provide regular and timely feedback and reports to medical and behavioral health administrative leadership and other stakeholders pertaining to Care Coordination service operations, as requested or necessary. In these efforts, identify program achievements as well as barriers, suggestions for improvement, and new service opportunities.
3. Maintain and evaluate the need for improvements to Care Coordination workflows and program support documentation, e.g., EHR and data collection
workflows, staff onboarding checklists, program manuals, workflow and documentation guides, and BH screening, warm handoff/triage, and referral criteria documentation.
4. Participate in required administrative, clinical, and education/training meetings including clinical case assignment conferences, rounds, team huddles, and supervision meetings.
5. Work collaboratively with site and clinical administrators to ensure Care Coordination programming, goals and objectives meet the needs of NAHC members.
6. Support grant projects and contracts that apply to the Care Coordination service. Facilitate or participate in associated meetings, quality improvement efforts with project managers and support staff. Ensure deliverables are met and required reports/data are submitted in a timely manner. Actively participate in county meetings and work with NAHC administration to identify, evaluate, and apply for new project opportunities.
Direct Service
1. Manage a diverse caseload of adults, youth, and families with a shared understanding of the respective roles and responsibilities of team members to
ensure that collaboration is efficient.
2. Screen and assess members for common mental health, substance abuse, and social resource needs.
3. Develop, implement, and monitor individual plans of care using a culturally sensitive and strengths-based approach, to assist members and families to cope and/or restore social, emotional, financial and environmental factors that affect and/or are affected by illness.
4. Identifies members not improving on health/wellness goals and/or with urgent healthcare needs to assist with prioritization for treatment adjustment or case review with the treatment team.
5. Accurately and expediently complete electronic and case management systems documentation and other data collection components related to mental health services.
6. Meet mental health visit goals as required for various contracts.
7. Provide early intervention, direct services, referrals, and liaison services between agencies as needed to support members with medical, behavioral health, and social services needs to promote overall health.
8. Provide individual, group, and family crisis intervention and aftercare/discharge support. Link to emergency services as needed, as well as ongoing case
management, which may include interacting with police, psychiatric services, hospitals, and other community agencies and staff.
9. Provide member education about common mental health, substance abuse disorders, and chronic health conditions and available treatment options.
10. Work collaboratively to resolve differing perspectives, priorities and schedules among providers.
11. Develop and provide trainings for peers regarding Epic workflows and providing quality care.
12. Support IBH Manager with workflow development, testing, and updates.
13. Connect healthcare consumers and family members to other members of the healthcare team through face-to-face encounters known as “warm hand-offs.”
14. Represent the program, department and agency in a positive and professional manner at all times.
15. Provide appointment reminders to members and facilitate access to services.
16. Member Care: Demonstrate understanding and apply working knowledge of safety policies and ensuring safe member practices.
17. Employee Safety: Safely performs all duties; follow required protective protocols to ensure personal safety as well the safety of others.
18. Must maintain compliance with ergonomic safety standards; be mindful of posture and regularly practice ergonomic stretches.
19. HIPAA: Keep all protected health information (PHI) confidential and abide by HIPAA policies for the release and disclosure of any PHI. Will report
unauthorized use of disclosure of PHI immediately, to supervisor or HIPAA security officer.
20. Work well under pressure, meet multiple and often competing deadlines.
21. At all times demonstrate cooperative behavior with supervisors, subordinates, colleagues, clients and the community.
22. Other duties as assigned by Supervisor.
