Integrated Community Care Coordinator - Moffat County

Position Overview

The Integrated Community Care Coordinator will conduct outreach and perform assessments for Northwest Colorado residents, specifically those enrolled in Medicaid and Medicare throughout the Yampa Valley. This position will serve as a liaison between clients and healthcare providers, including specialty providers and human service agencies to reduce barriers to care and assure clients receive the care they need when they need it.

The Care Team works with clients to identify barriers to care, and develop a comprehensive goal-oriented care plan.

The successful candidate will exhibit the following:

• Culture Champion – Commitment to the Partnership’s mission and working with diverse partners.
• Results Producer – A results-focused orientation with a proven track record of exceeding goals.
• Agility – Ability to think strategically, foresee opportunities and challenges and adapt as needed.
• Strong Communicator – Excellent written and oral communication skills.
• Organization – Exceptional capacity to manage details, monitor progress and adjust accordingly.
• Action Oriented – Enjoys working hard, tackling challenges and is not afraid to take ownership of a situation.

Supervision Received:
The Care Coordinators are based out of the Routt or Moffat offices, supervised by the Care Coordination Program Manager.

Supervision Exercised:
None.

Conduct outreach and provide assessment of Routt, Moffat, and Rio Blanco County residents who are enrolled in Medicaid and Medicare.

• Provide a variety of indirect and direct care coordination to clients identified as in need of services. This includes:
• Form trusting collaborative relationships with clients and partner organizations and care coordinator II.
• Schedule and complete assessments, follow-up as needed, track results, referrals and recommendations in database.
• Meet with clients in public spaces or place of residence when appropriate to the clients’ needs.
• Track and monitor referrals of clients for reporting as requested.
• Accurately document interactions in population health data system (ESSETTE) to include client visits, needed services, phone calls, written correspondence and communication in appropriate computer system within 2 business days.
• Work closely with partner organizations such as Horizons, Lift Up, Department of Human Services and other members of the Navigation Network to complete care plans.
• Ability to connect with diverse client population, empathize, show compassion, perform assessments and develop and self‑management plan in partnership with client and possibly other community partner agencies.
• Coordinate care with providers, community partners and other patient navigators to provide outreach, referrals and support for Medicaid clients.
• Complete documentation and reporting as required by program and supervisor.
• Complete intakes of high‑risk patients, working in partnership with patient, family and other members of the healthcare team as needed to assess and prioritize patient’s physical needs, mental well‑being, family support system, financial resources and available community and government resources.

Educate and work with clients to develop a comprehensive, goal‑oriented care plan, including identifying barriers to care.

• Co‑create patient specific goals, objectives and measures that meet the patient’s needs and that have been identified through assessment.

Ensure that clients are connected to resources and community partners identified in their care plan.

• Provide technical assistance to CCT across the region around ESSETTE and work with Rocky to improve the data and reporting system.
• Collaborates with other Care Coordinators to ensure all program deliverables are being met and advise supervisor or CCT Coach of any needs for meeting deliverables such as monthly reporting, referrals, interventions, assessments, etc.

Collaborate with Care Coordination Supervisors and other Care Coordinators to ensure all program deliverables are achieved and program evaluations are conducted.

• Participate in regular staff meetings.
• Performs assigned work safely, adhering to organization and program established safety rules and practices.

Assess and document…