Care Coordinator

Overview

Job Title: Care Coordinator

Reports To: Program Director and Site Medical Director

Department: Operations

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.

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

• Work is sedentary and ambulant with occasional physical exertion (lifting 30 or more pounds, walking, standing, etc.). Must be able 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.
• Quality of hearing 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 able to cope with multiple situations. Risk of exposure to infections and other potentially infectious materials. Universal Precautions must be followed.
• Understand, support, and comply with workplace violence, ADA, EEOC, and Corporate Compliance programs; commit to worker safety and patient safety. Subject to work schedule and shift changes.

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.

• Substance Use Care Coordination supports the patient’s medical, behavioral health, and other healthcare needs through referrals to address biopsychosocial needs, including unstable housing, food insecurity, childcare, and other social determinants of health. Referrals are documented and tracked.
• Assists individuals in addressing barriers to completing referrals, such as transportation, and documents interventions and outcomes.
• Communicates the patient’s needs and preferences to the right people at the right time, sharing information securely and providing comprehensive care.
• Involves referrals to community programs and services, documenting and tracking referrals and outcomes; collaborates to address barriers to access.
• Facilitates use of community-based support modalities, including 12-step and other self-help programs, peer recovery services, social service agencies, and other resources appropriate to recovery.
• Organizes and participates in interdisciplinary care planning with monthly treatment team meetings and documents collaboration appropriately.
• Reviews the patient’s medical record, current status, and progress toward goals; assists in addressing barriers and determining team actions.
• Identifies new problems and goals and updates the IPOC action plan accordingly. Other duties as assigned.
• Addresses and documents all barriers…