Position Summary: The Care Coordinator requires independent decision making skills to effectively work with program participants using the triple aim model to reduce systems fragmentation and address the social determinants of health.
- Manage a case load of program participants using a multi-disciplinary, multi- sector model.
- Integrate the bio psychosocial (medical, behavior health and social) approach into a comprehensive patient care planning process.
- Assess behavioral health and patient engagement utilizing departmental assessment tools.
- Incorporate all information obtained from assessments and establish a plan of care that will ensure outcomes that result in the participants increased engagement in their health care, establishment of a medical home, access to medication, decreased inappropriate use of the emergency room for non-emergent care and linkage to all the social supports necessary to manage the participant’s health care needs.
- Demonstrate the ability to work collaboratively with community and health care partners in planning wrap around services including but not limited to health education, food insecurities, housing and employment.
- All interactions require an exemplary level of core customer service skills and competency.
- Document using the approved software in a timely and effective manner adhering to policies and procedures related to HIPAA.
- Participate and engage in outreach activities within the community.
- Attend and participate in Care Coordinator and Department staff meetings.
- Facilitate case staffing.
- Other duties as assigned - Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee partner for this job. Duties, responsibilities and activities may change at any time with or without notice.
NOTE: Will be required to transport participants to healthcare appointments, as needed, utilizing TCCN departmental vehicle.
- Bachelor’s Degree Social work or related Human Service field, required.
- Master’s degree, preferred.
- A minimum of three (3) years’ experience in a human service setting, required.
- Proficient communication skills, both oral and written, required.
- Proficient PC skills and experience of Windows and Microsoft office programs, required.
- Demonstrated experience in diplomacy and ability to contribute to team goal setting and program development.
- Valid and in good standing South Carolina driver’s license, required.
- Personal transportation to be able to visit various “work locations” throughout the region, required.
- Home visits, required.
- Ability to work weekends and attend evening events as needed.
Physical Requirements: Light-Medium Physical Agility Test (PAT) Rating
While performing the duties of this job, the employee is frequently (activity or condition exists from 1/3 to 2/3 of the time) required to stand, sit, and walk; frequently to use hands, fingers; and frequently to talk or hear. The employee must exert 15 to 20 pounds of force occasionally (activity or condition exists up to 1/3 of the time), and/or 5 to 10 pounds of force frequently, and/or greater than negligible up to 5 pounds of force constantly to move objects.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.