Job Purpose: Care Coordination The Care Coordination program is a collaborative, comprehensive, integrated and interdisciplinary-focused Coordinated Care Organization (CCO) program staffed with team members focused on addressing interrelated medical, social, cultural, developmental, behavioral, educational, spiritual and financial needs in order to achieve optimal health and wellness outcomes for each member in need. This position is responsible for member-focused, individualized care coordination plans and providing community-based care coordination for members with high health care needs, including members with complex behavioral concerns, severe and persistent mental illness (SPMI), substance use disorders (SUD), and/or receiving facility based, in-home or community-based psychiatric services. The Care Coordination Specialist utilizes clinical expertise in behavioral health conditions and knowledge regarding the adult and children’s system of care to provide coordination that focuses on the member, is strengths based, trauma-informed and culturally and linguistically appropriate. This position is also responsible for providing oversight and guidance to Traditional Health Workers (THW) and assisting with the development of department processes and Care Coordination program compliance. Qualifications, Education, & Experience - Current Qualified Mental Health Professional (QMHP), may consider candidate who meets eligibility to apply for QMHP and willing to obtain within one year of employment
- Certified Case Manager preferred, or willing to obtain
- Motivational interviewing and teaching experience a plus
- Master’s degree in social work or counseling
- Experience in mental health, substance abuse treatment or other specialized populations strongly preferred
- Three year’s experience in case management/care coordination strongly preferred
Essential Responsibilities: Care Coordination - Maintain a small caseload of the most complex care coordination members to provide services to members receiving treatment in higher levels of behavioral health care
- Assess, identify, and respond to care coordination needs and screening services in order to implement Care Coordination program to members in a timely manner
- Identify risk factors and service needs that may impact member outcomes and address per guidelines
- Utilize a trauma-informed and Culturally Linguistically Appropriate approach to provide member-focused care and support
- Utilize assessment information to develop individualized care coordination plans for assigned members, analyzing the complex needs associated with high-risk medical conditions, mental health conditions, SPMI and SUD
- Identify suspected abuse and neglect issues and appropriately report to mandated authorities
- Manage the referrals of members whose needs may be complex but brief or short term, coordinating more intensely with other agencies to resolve acute needs or situations, which do not require ongoing care coordination contact
- Critically evaluate, prioritize, and assign each care coordination referral to the THW with the most aligned skills and experience needed for the case
- Build and maintain strong relationships and collaborative efforts with behavioral health treatment providers, crisis services, Developmental Disability, APD, DHS, state and county case workers, community partners, provider network, wraparound teams, and other relevant parties to facilitate care coordination plans and member needs; to also build on additional referral pathways
- Be a resource and provide specialized guidance to provider point of contacts for complex, high-risk cases
- Regularly attend and participate in interagency meetings for acute psychiatric, high-risk case and complex cases, collaborating with local hospitals and behavioral health agencies, including THW Hub meeting
- Assist and ensure care coordination services are offered in transition/discharge planning for members discharging from acute care settings or those who are transitioning from long term care, psychiatric inpatient settings, or other residential facilities to ensure a smooth transition back to community-based supports; may participate in monthly discharge planning meetings
- Coordinate care for members residing outside of service area as required in contract
- Utilize electronic record platform to assess Emergency Department (ED) utilization with risk stratification methods to identify high risk/high need members who may benefit from care coordination support, notifying appropriate staff of members who appear to have moved out of the area
- Make contact attempts to the highest risk/high ED utilization members, assessing current needs and medical, behavioral health, SUD co-morbidities; to review and offer care coordination support resources to reduce ED utilization and improve overall health and well-being
- Use and update various electronic records to update member information, care plans and guidelines, outlining important information for interagency care teams
- Within electronic record, track the assignment of new care coordination referrals, assist with the identification of referral source, priority population group and triggering event identifiers
- Assist in the implementation and development of electronic record diagnostic codes to monitor and for development of care coordination specific cohort groups
- Facilitate reoccurring meetings with care coordination team and other internal teams to review and ensure communication of care plans for care coordination members
- Serve as a resource to the organization on mental health and alcohol and other drug topics and issues
- Provide coaching and training on specific job responsibilities to new employees in Care Coordination Department
- Assist Director of Care Coordination with regularly scheduled training and education to provider network on the availability of care coordination services and other support services available to members
- Participate in quality and organizational process improvement activities and teams when requested
- Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
- Handle confidential information and materials appropriately and maintain a secure work area
- Other duties as assigned
Essential Responsibilities: ORGANIZATIONAL TEAM MEMBER - Participate in quality and organizational process improvement activities when requested
- Support and contribute to effective safety, quality, and risk management efforts by adhering to established policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities
- Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
- Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
- Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer’s expectations
- Recognize new developments and remain current in care management and coordination best practice standards and anticipate organizational modifications
- Advance personal knowledge base by pursuing continuing education to enhance professional competence
- Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
- Represent organization at meetings and conferences as applicable
Knowledge, Skills, & Abilities: - Knowledge of evidence-based practices and requirements to evaluate existing standards and implement new procedures
- Understanding of principles of health care of populations
- Knowledge of OHP program requirements, benefit package, eligibility categories, and Oregon Division of Medical Assistance Program (MAP) rules and regulations preferred
- Knowledge of the Oregon Health Authorities Coordinated Care Organization required metrics
- Understanding of basic concepts of managed care
- Knowledge of Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for mental health and substance dependence/abuse diagnoses, ASAM (American Society of Addiction Medicine) criteria for alcohol and/or drug dependence treatment and Mental health
- Knowledge of best practices and treatment modalities
- Knowledge of co-morbidities that indicate potential for psychiatric de-compensation and/or relapse
- Knowledge of the Oregon Health Plan benefit package, eligibility categories, and Oregon Medical Assistance Program (MAP) rules and regulations
- Knowledge of Medicare parts A and B benefit packages and the Centers for Medicare and Medicaid Services (CMS) rules and regulations and community resources
- Ability to maintain timely and accurate documentation per policy and procedure
- Collaborate with members, providers, and community partners to develop plans to address complex care needs and monitor and evaluate a plan of care for optimal outcomes
- Ability to manage multiple tasks and to remain flexible in a dynamic work environment and work autonomously and effectively set priorities
- Critical attention to detail for accuracy and timeliness
- High degree of initiative, judgment, discretion, and decision-making
- Ability to exercise sound clinical judgment, independent analysis, critical thinking skills, and knowledge of health conditions to determine best outcomes for members
- Ability to report to work as scheduled, and willingness to work a flexible schedule when needed
- Proficient in Microsoft Office Suite and Windows Operating System (OS)
- Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access
- Knowledge and understanding of how the positions’ responsibilities contribute to the department and company goals and mission
- Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse
- Awareness and understanding of equity, diversity, inclusion, and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social, political, and environmental contexts of policies, programs, and practices
- Excellent people skills and friendly demeanor
- Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
- Attention to detail and organization skills
- Ability to handle stress and sensitive situations effectively while projecting a professional attitude
- Ability to communicate professionally, both conversing and written
- Ability to work with diverse populations and interact with people of differing personalities and backgrounds
- Sensitive to economic considerations, human needs and aware of how one’s actions may affect others
- Ability to organize and work in a sensitive manner with people from other cultures
- Poised; maintains composure and sense of purpose
Working Conditions: This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information. Work Condition: [hybrid work] Employee generally works within the interior of an office or remote work from home environment. Employee may travel locally and be responsible for own transportation. Out of area travel may be required on occasion. Hours of operations and specific staff scheduling may vary based on operational need. The office environment is clean with a comfortable temperature and moderate noise level. Exposed to: Onsite: Cold/heat controls, close contact with employees and the public in office environment. Remote: Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output. Machines, equipment, tools, and supplies used: Constantly operates a computer or other office productivity machinery, such as postage machine, fax, copier, calculator, multi-line telephone system, scanner. May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information. Multiple Duties: Must be able to work under conditions of frequent interruption and be able to stay on task. Other Information: This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of Advanced Health employees. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.
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