- Accountable for engaging andretaining health home members in care, coordinating and arrangingfor the continuous provision of services, supporting adherence totreatment recommendations, monitoring and evaluating their needs,including prevention, wellness, medical, specialist and behavioralhealth treatment, care transitions, and social and communityservices where appropriate through the creation of an individualplan of care.
- In collaboration with the healthhome members, their family and/or caregivers, and other serviceproviders develops, manages and coordinates a comprehensiveindividualized person-centered care plan that coordinates andintegrates the continuum of medical, behavioral health services,rehabilitative, long term care and social service needs and clearlyidentifies the primary care physician/nurse practitioner,specialists, behavioral health care providers, care manager andother providers directly involved in the individual'scare.
- Ensures the availability of priorityappointments for health home members to care services includingphysical, psychiatric, and substance abuse within their health homeprovider network to avoid unnecessary, inappropriate utilization ofemergency room and inpatient hospitalservices.
- Reassesses needs for Health Homeservices and reviews health home members' historical ortargeted clinical measurements (i.e. number of ER visits andinpatient psychiatric admissions).
- Identifiespotential barriers to successful care and resolutions to thosebarriers.
- Completes contact notes, incidentreports, and other required documentation and maintains accuraterecordings in electronic case files in a requested timelyfashion.
- Outreach via phone to health homemembers between visits (check on self-care, medication fills,treatment plan, schedules visits, tests/follow-up) Monitors thatthe health home member completes post-visit follow-up (fillprescriptions, make appointments).
- Refer healthhome members to peer supports and coordinate peer supports, supportgroups, and self-care programs to increase client's andcaregivers knowledge about the individual's diseases,promote the health home members' engagement andself-management capabilities, and help the to improve adherence totheir prescribed treatment order to allow them to make informeddecisions.
- Assure timely and comprehensivetransitional care from an inpatient facility (hospital,rehabilitative, psychiatric, skilled nursing or treatment facility)to follow-up with post discharge interventions in order to preventhealth home member's avoidable readmission afterdischarge and to ensure proper and timely follow upcare.
- Develops and maintains health homenetworks with primary medical and specialty practitioners andmental health providers, substance abuse service providers,community based organizations, managed care plans, emergency rooms,hospitals, and residential/rehabilitation settings, community-basedservices to ensure coordinated, and safe transition in care for itspatients who require transfer to/from sites ofcare.
- Utilizes regional health informationorganizations (RHIOs) and other data systems to track and sharehealth home members' information and care needs acrossproviders, monitor their outcomes, and initiate changes in care asnecessary to provide the health home prompt notification of anindividual's admission and/or discharge to/from anemergency room, inpatient, or residential/rehabilitation settingand address immediate needs in order to maximize optimum care andtimely treatments, services andreferrals.
- Utilizes and electronically tracksall specialty medical, behavioral, and support service referralsmade for health home members, and ensures that the member followsup and receives all of the care they need. Tracks and arrangesappointments, educate health home members and coordinate allaspects of the member's health and communityservices.
- Able to utilize technologyconferencing tools including audio, video and /or web deployedsolutions and accountable for hand-held devices (I Phone,Blackberry, I Pad, Tablets, Laptops,etc.).
- Makes sure that health homemembers' entitlements, insurance and benefits are inplace. Provides interpreter services asrequired.
- Responsible for direct serviceprovision of services to the consumer based on needs as establishedand documented in comprehensive assessments and service plans. Thiswill be re-evaluated and adjusted every 6 month direct s or asneeded (as per SOMH CAIRS requirements).
- Workschedule includes holiday coverage to accommodate the coverageneeds of the program when required. 24 hours/seven days a weekavailability to provide information and emergency consultationservices and provide escorts to health home members from ER,hospital and other settings to alternative level ofcare.
- Attends required in-service programs andtrainings.
- Collaborate with program managementin the identification of developing marketingstrategies.
- Request in a timely fashionscheduled vacation and time off request from the Clinical Managerto ensure continuous coverage of program'sactivities.
- Performs other related duties asrequested or assigned by agency management.
- Bachelor's degree in socialwork, psychology or a related health/human services field with two(2) years of direct work with the target population. ORDegree/certification in Medical and Clinical Assistance or Healthprofessional field.
- Knowledge of the communitymedical resources and their financialrequirements.
- Good oral and writtencommunication skills.
- Fluency in secondlanguage preferred
- Ability to work flexiblehours and days – including weekends/evenings/holidaysaccording to needs of a 24/7 program.
- Able tolift up to 10 pounds.
- Able to climb stairs andmake home visits.
- Able to stretch and bend toretrieve files.
- Able to operate a computerkeyboard, mouse, & officeequipment.
- Able to read printed materials andcomputer screens.
- Able to sit and work on thecomputer for long periods of time.
- Able totravel to multiple locations as needed.
- We offer competitive salary andexcellent benefits including:
- Generous time off(Vacation/ Personal Days/ Sick Days/ Paid Holidaysannually)
- Medical,
- Dental
- Vision
- RetirementSavings with AgencyMatch
- Transit
- FlexibleSpending Account
- Lifeinsurance
- Public Loan Forgiveness QualifiedEmployer
- Training Series and other additionalvoluntary benefits.
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Care Coordinator - Dubai, United Arab Emirates - ClickJobs
Description
QUALIFICATIONS:
BENEFITS:
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