Care Coordinator

Job Title: Care Coordinator

Reports To: Program Director and Site Medical Director

Department: Operations

Purpose:

Care Coordinators must be organized, personable, and capable of balancing the needs of multiple patients as well as their healthcare providers and insurance representatives to address barriers that will ensure the patient can navigate their recovery experience by demonstrating the following skills: active listening, service orientation, social perceptiveness, critical thinking, time management, active learning, good judgment and decision making, verbal communication skills, and ability to monitor for progress and needed interventional actions.

Duties:

The Care Coordinator will act as an integral member of the ReVIDA Recovery multidisciplinary team by supporting patients in obtaining their individualized goals, by building and strengthening linkages with community resources and family members by deliberately organizing patient care activities and sharing information among all the participants concerned with a patient’s care to achieve safer and more effective care. The Care Coordinator will assist individuals in opioid use disorder treatment in developing a service plan, referrals, and linkage, ensuring the patient has access/continuity of care throughout the mental health and primary care system, ensuring each patient has resources to acquire medication, has transportation for appointments, and attends appointments. The Care Coordinator will ensure individuals have access to psychosocial rehabilitation, support, employment, and housing options while encouraging the individual to utilize community/natural supports to assist in managing substance use disorders.

Physical, Emotional Demands, and Work Conditions:

• Work is sedentary and ambulant with occasional physical exertion (lifting 30 or more pounds, walking, standing, etc.) ability to support patient weight in case of emergency or disability requiring assistance. Must be able to see, stoop, sit, stand, bend, reach, and be mobile (whether natural or with accommodation).
• Quality of hearing (whether natural or with accommodation) must be acceptable. Must be able to communicate both verbally and in writing. Must be able to relate to and work with mentally and physically ill, disabled, emotionally upset, and hostile patients.
• Must be emotionally stable and exhibit the ability to display coping skills to deal with multiple situations. Risk of exposure to infections, bloodborne pathogens, and other potentially infectious materials or contagious diseases. For this reason, "Universal Precautions" must always be followed.
• The care coordinator should understand, support, and comply with the established workplace violence, ADA, EEOC, and Corporate Compliance program and commit to worker safety, health, and patient safety. Subject to work schedule and shift changes.

Supervision/ competency evaluations: Supervision and competency evaluations are provided through facility monitoring activities, direct observation, staff meetings, in-services, management meetings, individual meetings, Employee Improvement processes, reporting, interactions, strategic planning, outcomes, and annual competency review.

Competencies:

• Substance Use Care Coordination supports the patient’s medical, behavioral health, and other healthcare needs through the facilitation of necessary referrals to help meet the overall biopsychosocial needs of the patient. This includes addressing needs beyond the patient’s medical status and issues such as unstable housing, food insecurity, childcare, and other social determinants of health. Referrals are documented and tracked.
• Additionally, the Care Coordinator assists individuals in addressing any barriers to completing recommended referrals, such as transportation issues, and documents these interventions and outcomes.
• Care coordination includes communicating the patient’s needs and preferences at the right time to the right people by sharing and securely using the information and providing practical and comprehensive care to the patient.
• This role requires referrals to community programs and services and appropriately documenting and tracking referrals and outcomes. The Care Coordinator collaborates and documents all efforts to help the member address any barriers to access to appropriate community-based referrals.
• Care Coordination includes the appropriate use of and facilitation of referral to various community-based support modalities, including consideration of referral to 12-step and other self-help programs, peer recovery services, social service agencies, and other community-based resources appropriate to the member’s recovery.
• Organizes and participates in interdisciplinary care planning that consists of at least monthly meetings of the multidisciplinary treatment team (including all relevant medical and behavioral health care professionals involved in providing and coordinating the member’s care) and documents this collaboration appropriately.
• The Care Coordinator, in participating in the interdisciplinary treatment team meeting, will review the patient’s complete medical record (including urine drug screens and laboratory tests), discuss the current status of the patient’s progress toward meeting their goals as specified in their plan of care, assist in addressing any barriers toward the individual’s progress in meeting their identified treatment goals as well, as the actions which the treatment team will undertake to address those barriers.
• The Care Coordinator will participate in identifying any new problems and goals and modification of the IPOC action plan accordingly. Other duties, as assigned.
• Effectively addresses and documents all barriers to completing any community-based referrals and patient needs.
• Tracks and maintains accurate and thorough documentation of referrals in the patient’s medical record.
• Creates an Individualized Plan of Care (IPOC) in collaboration with Multidisciplinary Treatment Team, utilizing the required Department of Medical Assistance Services (DMAS) template, within 30 days of admission.
• Promptly reviews and updates the Individualized Service Plan (ISP) at 90-day intervals and Individualized Plan of Care (IPOC) every 30 days as required.
• Organizes and participates in interdisciplinary care planning with the treatment team at least monthly.
• Effectively collaborates with all members involved with providing and coordinating patient care.
• Creates Individualized Aftercare Plan and Discharge Plan with collaboration from Multidisciplinary Treatment Team members.
• Demonstrates thorough understanding of all Department of Medical Assistance (DMAS) of Virginia Addiction Recovery Treatment Services (ARTS) program requirements and Office Based Opioid Treatment (OBOT) guidelines; seeks clarification or guidance if unsure.
• Maintains attention to detail, actively proofreads and edits written communication & patient documentation.
• Effectively directs and organizes daily responsibilities & workflow.
• Establishes and maintains appropriate boundaries with patients, treatment team, and colleagues.
• Applies knowledge and experience to solve problems; consults with others as needed.
• Listens attentively and proactively asks questions for clarification as needed.
• Works in collaboration with Multidisciplinary Treatment Team members

Care Coordinator Requirements:

Experience:

• One year of previous experience working with SUD/OUD/BH populations required
• Special Requirements: Knowledge of the disorder process of substance use disorders, dual diagnoses, opioid use disorder, and recovery support services required.

Licensure:

• Virginia: RN, CSAC, CSAC-R, CSAC-A, BSW, or Equivalent
• Must be registered with the Board of Virginia

Special Requirements: Knowledge of applicable State Code of Regulations and 42 Code of Federal Regulations (CFR) Part 2. Compliance with accepted professional standards and practices; Ongoing adherence to the NAADAC Code of Ethics and any other applicable Codes of Ethics for their respective profession.

Continuing Education & Professional Licensing/Certification Requirements: The employee is expected to participate in appropriate continuing education as requested and required by their immediate supervisor. In addition, the employee is expected to accept personal responsibility for other educational activities to enhance job-related skills and abilities. The employee must attend mandatory educational programs and maintain current professional certifications as delineated above in their state, in good standing.

While this job description is intended to reflect the job requirements, management reserves the right to add or remove duties from jobs when circumstances (e.g., emergencies, changes in workload, rush jobs, or technological developments) dictate. Furthermore, they do not establish an employment contract and are subject to change at the employer’s discretion.