Care Coordinator-CC536501

The Care Coordinator functions as a member of an interdisciplinary team to provide care coordination to a caseload of severely mentally ill adults with multiple medical comorbidities and/or co-occurring substance abuse disorders and/or medically ill individuals. Advocates for and supports the client, engages with community agencies/health care providers and others on his behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations. Provides clinical support to the Team by providing consultation, education, information around psychosocial and/or substance abuse conditions, interventions, resources to maintain focus on outcomes and best practices.

Essential job functions

• Conduct initial and ongoing assessments of assigned children to document strengths, needs, goals, and resources Advocate and support the child in collaboration with family, engage with community agencies/health care providers and others on his/her behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations. Coordinate care planning with other providers of services/ resources to ensure goal directed, collaborative care, including care transitions
• Provide clinical coordination support to the team by providing consultation, education, information around psychosocial conditions, interventions, resources to maintain focus on outcomes and best practices.
• Participate in the development/documentation /review and update of client centered comprehensive integrated, interdisciplinary care plan in consultation with other team members as an integral part of the CCBHC multidisciplinary team, including family care planning and collaboration.
• Conduct warm hand-off referrals to appropriate services and supports.
• Assist administrative staff in collection of information for program effectiveness.
• Maintain accurate clinical records in compliance with all city, state, and federal regulations.
• Participate in all training programs for the Whole Family Health Model.
• Attend individual supervision with clinical supervisor.
• And other duties as assigned

Essential knowledge, skills and abilities

• Experienced in and demonstrated comprehensive understanding and working knowledge of the interdisciplinary planning process and the developmental treatment model.