Care Coordinator I
Company: Spectrum Health and Human Services
Location: Buffalo
Posted on: May 27, 2023
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Job Description:
Agency Profile: Spectrum Human Services respectfully partners
with adults, children and families as they recover from behavioral,
emotional, mental health and/or substance related disorders by
offering individualized and meaningful opportunities of hope,
empowerment and support to achieve self-defined improvements in
their quality of life.
Full-time: 1280 Main Street, Buffalo, NY
SUMMARY OF POSITION FUNCTION:
The Care Coordinator will apply the essential activities of case
management which include assessment, planning, coordination,
monitoring and evaluation with the core components (Comprehensive
Case Management, Care Coordination & Health Promotion,
Comprehensive Transitional Care, Patient and Family Support and
Referral to Community & Social/Support Services). The Care
Coordinator will be responsible for the following outcomes: to
reduce utilization associated with avoidable and preventable
inpatient stays, to reduce utilization associated with avoidable
emergency room visits, to improve outcomes for person with mental
health illness and/or substance use disorders and to improve
disease-related care for chronic conditions.
MAJOR DUTIES AND RESPONSIBILITIES:
Complete a comprehensive health assessment/reassessment inclusive
of medical/behavioral/rehabilitative and long term care and social
service needs.
Complete/revise an individualized patient centered plan or care
with the patient to identify patient's needs/goals, and include
family members and other social supports as appropriate.
Consult with multidisciplinary team on client's care
plan/needs/goals.
Conduct outreach and engagement activities to assess on-going
emerging needs and to promote continuity of care and improved
health outcomes.
Consult with primary care physician and/or any specialists involved
in the treatment plan.
Prepare client crisis intervention plan.
Coordinate with service providers and health plans as appropriate
to secure necessary care, share crisis intervention and emergency
information.
Link/refer client to needed services to support care plan/treatment
goals, including medical/behavioral health care; patient education,
and self help/recovery, and self management.
Conduct case conferences with an interdisciplinary team to monitor
and evaluate client status.
Advocate for services and assist with scheduling of needed
services.
Coordinate with treating clinicians to assure that services are
provided and to assure changes in treatment or medical conditions
are addressed.
Monitor/support/accompany the client to scheduled medical
appointments.
Follow up with hospitals/ER upon notification of a client's
admission and/or discharge to/from an ER,
hospital/residential/rehabilitative setting.
Facilitate discharge planning from an ER,
hospital/residential/rehabilitative setting to ensure a safe
transition/discharge that care needs are in place.
Notify/consult with treating clinicians, schedule follow up
appointments, and assist with medication reconciliation.
Link client with community supports to ensure that needed services
are provided.
Follow-up post discharge with client/family to ensure client care
plan needs/goals are met.
Develop/review/revise the individual's plan of care with the
client/family
Consult with client/family/caretaker on advanced directives and
educate on client rights and health issues, as needed
Meet with client and family, inviting any other providers to
facilitate needed interpretation services.
Refer client/family to peer supports, support groups, social
services, entitlement programs as needed.
Identify resources and link client with community supports as
needed
Collaborate/coordinate with community base providers to support
effective utilization of services based on client/family need.
Maintains complete, current and accurate member files which comply
with The Health Home Standards. Documents all member related
activity in a progress note by the conclusion of the next business
day.
Frequent or occasional driving of personal vehicle for purpose of
transporting clients in the community and/or site visits (client or
work related)
Other duties as requested.
SKILLS/COMPETENCIES:
Effective verbal and communication skills
Ability to teach and influence others
Demonstrated ability to work effectively in a team environment.
Demonstrated effective interpersonal relationship and customer
services skills
Good organizational and time management skills
Ability to work effectively with people from diverse cultures and
socioeconomic conditions.
Actively listens to others to understand their perspective and
ensure understanding regardless of barriers.
Homelessness or chemical dependence. Experience with families
preferred.
Critical thinking ability
Ability to handle protected health information (PHI) in a manner
consistent with The Health Insurance Portability and Accountability
Act of 1996.
Knowledge of computerized systems.
Knowledge of local and surrounding area resources
EDUCATION REQUIREMENTS:
High School diploma plus 2 years qualifying experience* OR
-preferred- Associate's degree in health, human or education
services with 1 year of qualifying experience* OR LPN with
experience.
Certified Peer or a peer that has the potential to receive
certification.
EXPERIENCE:
Must possess a valid Driver's License with a satisfactory driving
record, and possess a personal vehicle for job requirement
Keywords: Spectrum Health and Human Services, Buffalo , Care Coordinator I, Other , Buffalo, New York
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