Community Resource Coordinator​/Weekend Shift

Community Resource Coordinator

Under the direction of the Social Services Lead, the Community Resource Coordinator (CRC) is essential to the success of meeting high risk patient's needs post- discharge and preventing unnecessary re-admissions. The CRC functions across the care continuum, interfacing with the multi-disciplinary team to facilitate the best possible clinical outcomes and optimal level of wellness with the most appropriate resources. The CRC is knowledgeable in social services and behavioral health for specific populations and chronic diseases.

This position requires both internal and external interface with providing psychosocial resources to populations that connect with health insurance attributed lists, emergency rooms, home health, outpatient specialty care, hospitals, primary care services. The CRC will collaborate with the interdisciplinary team to identify, assess, plan, implement, coordinate, monitor, and evaluate options and services in meeting the needs of individuals and their complex psychosocial needs.

Essential Functions

- Performs psychosocial assessments on patients to determine patient and family's strengths and needs relative to coping effectively with diagnosis, treatment and follow-up cares. If patient is determined to be high-risk, refer them for immediate evaluation as appropriate.

- Adds to the multidisciplinary care plan with patient and family input and based on mutual goals to address psychosocial barriers.

- Uses a range of therapeutic and other interventions, including support, motivational interviewing and education to address issues in each phase of the illness.

- Assists patient in setting up advanced directives (including medical power of attorney and medical healthcare power of attorney).

- As needed, aids in securing resources to meet financial, transportation, housing and other needs.

- Liaison with local Behavioral Health services and resources.

- Case manages patients with a primary behavioral health or substance abuse diagnosis.

- Develops a relationship with primary care, specialty services, home health, emergency and hospital networks required for inter-disciplinary care management

- Utilizes hospital, community and national resources to maintain and enhance knowledge and expertise of the community care management team.

- Ensures appropriate documentation in the electronic medical record.

- Respects and upholds patient rights, demonstrates professional integrity, maintains patient confidentiality, discloses all potential or perceived conflicts of interest when appropriate; accepts responsibility and accountability for professional competence.

- Monitors outcomes and develops process change to improve care.

Other Duties

- Participates in departmental and association wide informational meetings and in services, including staff meetings, association wide forums, and seminars.

- Reviews department and association wide policies and procedures annually. Develops and maintains new policies and procedures as needed.

Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

Abilities

- This position requires experience in various situations involving crisis intervention, mediation, counseling, and behavioral health legalities.

- This employee must be service oriented and have excellent customer service skills, computer skills, organizational skills, multitasking skills, professional interpersonal skills, time management skills, public speaking skills, critical thinking skills, the ability to prioritize work, and telephone etiquette.

- This position requires knowledge of general office equipment (including the nurse call system, telephone system, fax machine, copy machine, computer, and commonly used…