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Care Coordinator

4 months ago

Jamestown, United States Evergreen Health Full time
Job DescriptionJob Description

Evergreen Health

The Care Coordinator applies 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 & Family Support and Referral to Community & Social/Support Services). The Care Coordinator will be responsible for the following outcomes: Reduce utilization associated with avoidable and preventable inpatient stays, reduce utilization associated with avoidable emergency room visits, improve outcomes for persons with mental health illness and/or substance use disorders; and improve disease-related care for chronic conditions. As part of the Essential Functions for this role, the Care Coordinator:

  • Delivers core services in accordance with Health Home standards to patients on assigned caseload. Achieves monthly and quarterly productivity expectations.
  • Completes a comprehensive assessment within 60 days of patient’s enrollment and an annual reassessment inclusive of medical, behavioral, social, and rehabilitative needs.
  • Completes individualized patient-centered care plan with the patient within 60 days of enrollment and updates monthly to identify patient’s needs and goals, and includes family members and other social supports as appropriate. The Care Plan is also amended annually.
  • Completes and amends patient crisis plan. Coordinates with service providers and health plans as appropriate to secure necessary care during a crisis, share crisis intervention and emergency information.
  • Coordinates with multidisciplinary team on patient’s care plan, including but not limited to the primary care physician and/or any specialists involved in the treatment plan.
  • Links and refers patients to needed services to support care plan including medical and behavioral health care, patient education, entitlement programs, self-help groups, and recovery and self-management. Attends appointments with patient as necessary. Assists patient with transportation needs when necessary to include transportation of the patient when no other means are available.
  • Conducts diligent search activities to ensure patient engagement and to assess on-going emerging needs in order to promote continuity of care and improve health outcomes.
  • Conducts annual case review with interdisciplinary team to monitor and evaluate patient status.
  • Follows up with patient upon notification of ER or inpatient admission and/or discharge and facilities transitions of care within 24-48 hours.
  • Advocates for interpretation services and utilizes translation line as needed
  • Maintains complete, current, and accurate patient charts that comply with the Health Home Standards.
  • Documents all patient-related encounters and chart activities in a progress note within 24-48 hours, including encounters with patient, providers, and other members of the care team. Attempted contacts and completion of documentation (such as the assessment and care plan) must also be documented in the form of a progress note.
  • If applicable, completes the General Assessment with patients eligible to be enrolled and/or enrolled in Health and Recovery Plans (HARP) however are not interested in pursuing these services at this time.
  • If applicable, enters data collected from the Eligibility Assessment into the NYS Health Commerce System. Submits the results of the Eligibility Assessment to MCOs for approval and service determination.
  • If applicable, completes the HARP Health Plan Summary with HARP enrolled patients, communicates with MCOs and Home and Community Based Services (HCBS) providers to ensure referral and linkage to services outlined in the Health Plan Summary.

Qualified Candidate will have a Bachelor’s degree in health, human or education services and one year of qualifying* experience or Associate’s degree in health, human or education services and two (2) years of qualifying* experience. Qualifying* experience equals professional case management or care coordination experience with the following populations: persons with a chronic illness, and/or persons with a history of mental illness, homelessness, or chemical dependence. Candidate must have a valid NYS Driver’s License and an insured, dependable car. Sensitivity to cultural diversity, people living with HIV/AIDS and lifestyle and addiction issues essential.

Job Type: Full-time

Required education: Bachelor’s (plus 1 year experience); Associates (plus 2 years experience)

Required experience: Care Coordination/Case Management; Working with clients experiencing chronic illness, homelessness, mental illness and/or chemical dependence

Additional requirements: Must have dependable, insured vehicle and NYS Driver’s License


What Evergreen Health Offers You:

  • Remote hybrid schedules may be available for this position
  • Opportunities for overtime hours may be available for this position
  • Multiple comprehensive medical health insurance plans for you to choose from
  • Dental and Vision coverage at no cost to you
  • Paid Time Off package that equals 4 weeks of time in your first year
  • 403b with a generous company match
  • Paid parking or monthly metro pass
  • Professional development opportunities
  • Paid lunch breaks