Description of Position:
Serves as a member of an interdisciplinary team that provides recovery oriented in- home and community based services for adults and children who have Illinois Medicaid with various medical, mental health and substance use disorder needs. The Care Coordinator also manages a waiver population to work to get services in the home for members who qualify to help them remain safe in their home. The Precedence Care Coordination Entity (PCCE) Care Coordinator will provide comprehensive care coordination services for adults and children, health promotion, individual and family support, referrals to community agencies, assessments, treatment planning and access to Aging, Physical Disability, Traumatic Brain Injury or HIV/AIDS Waiver services if appropriate. The Care Coordinator delivers help home services to qualified members.
% of Time
· Care Coordination and Referrals: Outreach activities to members to engage in care coordination, conduct individualized, comprehensive, whole person assessments, schedule appointments, make referrals, track referrals, appointments and HEDIS measures, follow-up monitoring, communication with providers on goals, support coordination of care with primary care providers and specialists. Tracking of HEDIS measures, referral follow through, health risk assessment completion and other care model components. Care Coordinators will participate in joint treatment staffings- meeting with multidisciplinary treatment team and member/parent/guardian to plan for treatment and coordination; provide resource referrals or coordinate to primary are providers and specialists, wellness programs, support groups, school supports, housing services, substance abuse treatment, transportation services, employment and education programs.
· Health Promotion: Promoting members’ health and ensuring all personal health goals are included in person centered treatment plans. Promote substance abuse prevention, smoking prevention and cessation, nutritional counseling, obesity reduction and increased physical activity. Provide health education to members and family members, provide self-management support and development of self-management plans, promote self-direction and skill development in area of medication and medication adherence; Coordinate multiple systems for children with SED as part of a child and family-driven team process; Provide prevention education to members and families members about health screening, childhood developmental assessments and immunization standards and; Wraparound planning process: Identification, development and implementation of strengths0-based individualized care plans addressing the needs of the whole child and family.
· Comprehensive transitional care: Engage member and/or caretaker as an alternative to emergency room or hospital care; Participate in hospital discharge process; preform medication reconciliation; facilitate development of crisis plans; monitor for potential crisis escalation/need for intervention; follow up phone calls and face to face visits with members/families after discharge from the emergency room or hospital; identification and linkage to long-term care and home and community based services.
Basic UPH Performance Criteria
· Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.
· Demonstrates ability to meet business needs of department with regular, reliable attendance.
· Employee maintains current licenses and/or certifications required for the position.
· Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.
· Completes all annual education and competency requirements within the calendar year.
· Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff. Takes appropriate action on concerns reported by department staff related to compliance.
Disclaimer: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that required of the employee. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.
Requires a BA, BS, BSW in behavioral healthcare services related field.
Valid driver’s license when driving any vehicle for work-related reasons.
· Reads, writes, comprehends and speaks fluent English.
· Basic computer knowledge using word processing, spreadsheet, email, EMR and web browser.
· Team work
· Interpersonal skills
· Decision making skills
· Use of usual and customary equipment used to perform essential functions of the position.
· Work will require travel to other UPH facilities, community agencies, member homes, etc.