Jail Liaison Care Coordinator

As a Jail Liaison Care Coordinator this position provides person centered care transitions and care coordination support of individuals who have been detained. This position works with the jail's behavioral health and medical staff to evaluate the needs of the individual for successful transition into the community to prevent future detainment or incarceration. This position collaborates with the primary care manager supporting the individual in the community to ensure ongoing success in supporting the care plan developed prior to release.

This is a full-time hybrid opportunity. While there is no routine expectation to work onsite, the selected candidate must be available to report to the Alliance Home Office in Charlotte, North Carolina, for business meetings as needed. In addition, the successful candidate will be required to travel to Mecklenburg County detention facilities up to three times per week to meet with members as necessary.

Assessments

• Meet with member in-person in the jail setting
• Document consent to participate with care coordination and release planning
• Obtain necessary releases of information for coordination of care and collaboration for successful release to prevent future encounters with the justice system
• Complete an assessment of the individuals physical, psychological, social, environmental, and spiritual needs
• Provide education and supports to members and legal guardians regarding their rights and responsibilities, available service options, providers availability, and payer requirements
• With appropriate consent, as applicable, collaborate with formal and informal caregivers or support network, providers, and others in the member's interdisciplinary healthcare team to inform the assessment
• During member engagements and through available data related to resource utilization and quality metrics, monitor the member's condition and response to the care plan and interventions
• Document the assessment findings, including not limited to, the member's support systems (professional and informal), primary concerns, strengths, priorities, care need gaps, social needs, goals, etc.
• Document member and/or LRP agreement regarding the identified care needs, opportunities, and goals for intervention identified through the assessment
• Actively collaborate with the individual, jail professionals, and providers to develop a transition plan that adequately address barriers to prevent future encounters with the justice system

• Based on assessment and member identified priorities, develop a member centric and agreed upon care transition plan in collaboration with appropriate and applicable formal and informal caregivers or support network, providers, and others in the member's interdisciplinary healthcare team
• Use of a member-centric, collaborative partnership approach that is responsive to the individual member's culture, preferences, needs, and values
• Develop care plan with a comprehensive, holistic, and compassionate approach to care delivery that integrates a member's medical, behavioral, social, psychological, functional, and other need
• Consideration for the member's care needs, barriers, and opportunities in development of the care plan
• In collaboration with the member and their support network (formal and informal) include prioritized goals and outcomes to be achieved with associated interventions or actions needed to reach the goals
• Include appropriate, relevant, and realistic goals to align with member needs and priorities

• Facilitating awareness of and connections with community supports and resources
• Referral to community & social support services, including providing referral, information, and assistance and follow-up in obtaining and maintaining community-based resources and social support services while providing comprehensive assistance securing key health-related services (e.g., filling out and submitting applications)
• Foster safe and manageable navigation through the healthcare system to enhance the member's timely access to services and achieve desired outcomes
• Coordinate care, services, resources, and health education specified in the planned interventions
• Provide evidence of facilitation, coordination, and collaboration to support transitional care management activities. To include, not limited to, scheduling transportation, outpatient provider appointments and in-home services for timely access at time of release
• Facilitate and coordinate with…