Care Coordinator

General function

Care Coordinator(s) who, as part of a care team, act as the primary point of contact for member and family relationships. All care coordinators shall have, at minimum, a bachelor’s degree, or an RN and be licensed to practice in Tennessee;The person occupying this position provides direct and indirect services to Clients of Alliance Healthcare Service who are enrolled in Health Link. This person participates in outreach/consultation and education activities and assumes other responsibilities as delegated by senior staff.

Supervisory resposibility: None

Qualifications, knowledge and required training

• Bachelor’s degree in Psychology, Human Services or related field from an approved university training program.
• Must be eligible for any/all credentialing required by regulatory and funding sources.
• Must be able to travel independently in the community and to enter/exit private homes and other locations which may not be governed by accessibility standards required of certain public places in Tennessee.
• If traveling to perform duties by private vehicle, must hold valid driver’s license, meet Tennessee insurance standards, and produce evidence of driving records which meet the AHS’s liability insurance guidelines.
• This person must also demonstrate an ability to work effectively in a treatment setting dealing with emotionally or socially disturbed individuals.
• The Mental Health Specialist I must demonstrate an ability to use mature judgment in problem and operate effectively in a multi-disciplinary setting.

1. Comprehensive care management

• Initiate, complete, update, and monitor the progress of a comprehensive person-centered care plan as needed
• Example: creating care coordination and treatment plans

2. Care coordination

• Participate in member’s physical health treatment plan, support scheduling and reduce barriers to adherence for medical and behavioral health appointments, facilitate and participate in regular interdisciplinary care team meetings, follow up with PCP, proactive outreach with PCP, and follow up with other behavioral health providers or clinical staff
• Example: proactive outreach and follow up with primary care and behavioral health providers

3. Health promotion

• Educate the member and his/her family
• Example: educating the member and his/her family on independent living skills

4. Transitional care

• Provide additional high touch support in crisis situations, participate in development of discharge plan for each hospitalization, develop a systemic protocol to assure timely access to follow-up care post discharge, establish relationships, and communicate and provide education
• Example: participating in the development of discharge plans

5. Member and family support

• Provide high-touch in-person support, provider caregiver counseling or training, identify resources to assist individuals and family supporters, and check-ins with member
• Example: supporting adherence to behavioral and physical health treatment

6. Referral to social supports

• Identify and facilitate access to community supports, communicate member needs to community partners, and provide information and assistance in accessing services
• Example: facilitating access to community supports including scheduling and follow through

7. Additional detail regarding how Health Links will be paid for providing these 6 types of clinical activities can be found in the following section.

8. This section focuses on member-level activities; however, Health Link providers are required to continue to perform all activities outlined in the practice eligibility requirements in Section 2.2.

9. To provide designated number of monthly contacts.

10. To comply with policies and procedures as outlined in AHS’s policy and procedure manual.

11. Other duties may be assigned by supervisor(s) to meet the needs of the consumer and AHS.

Personal relationships

In order to appropriately accomplish his/her duties, the person occupying this position will be required to maintain effective relationships with the professional clinical staff and the clients of Alliance Healthcare Services.