TitleCase Manager - Care CoordinatorDescription
Wyandot BHN is seeking a dedicated Care Coordinator to join our team! The Care Coordinator affect improvements in the overall health of individuals seeking OneCare Kansas services by providing professional care management & coordination services.
Essential Job Duties:
- Engage individuals and families as partners in services and develop positive, hopeful, and trusting relationships.
- Manage the emotional distress experienced by clients and their families in avoiding and resolving crisis situations.
- Recognize and demonstrate sensitivity to cultural and ethnic differences.
- Help others succeed by demonstrating exceptional interpersonal skills and the ability to work with persons with severe mental illness and/or serious emotional disturbance, and the ability to react effectively in a wide variety of human service situations. Effectively manage conflict, promote change and growth, and inspire the development of all clients served.
- Build client relationships, as well as business relationships and strategic partnerships with other agencies and external resources.
- Complete all documentation and reporting requirements thoroughly and on time.
- Interact positively with other members of the agency and team, including active participation in supervision activities, team meetings, continuing education, etc.
- Regularly travel and transport clients and/or families in and around the region, and provide direct care and support as needed.
- Provide, coordinate, or otherwise ensure provision of the following six health home services in accord with the member s Health Action Plan:
Comprehensive Care Management
- Developing a health-based needs assessment to create a health action plan (HAP).
- Address barriers to success, i.e. low income, housing, transportation, health conditions, etc.
- Ensuring and monitoring that needed care and services are offered and accessible.
- Routine and periodic reassessment and revision of the HAP.
- Implementation and management of the HAP.
- Addresses needs, improves chronic conditions, and assists in the attainment of goals.
- Supports adherence follow HAP, chronic condition self-care, and continued participation in HH care.
- Coordinates and collaborates with other providers around health status and medication side effects.
- Engages supports/guardians in decisions regarding pain management, palliative care, and end-of life decisions.
- Assesses the HAP and monitors to evaluate intervention impact.
- Coordinates other supports in the community.
- Encourages health literacy, development of recovery plans, self-management, and provides resources to help manage or mitigate chronic conditions and prevent development of secondary conditions.
- Supports healthy ideas and behaviors to motivate management of health.
- Emphasizes self-direction, skill development, engaging supports, and using decision aids to evaluate the risks and benefits of treatment.
- Ensures all heath action goals are include in person centered care plans.
- Provides health education and coaching to members, family, and supports.
- Offers prevention education to members, family, and supports about proper nutrition, health screening, and immunizations.
Comprehensive Transitional Care
- Provides a comprehensive plan when discharging from hospitalization
- Schedules follow up appointments.
- Ensures medication information is communicated to providers to ensure care during transition.
- Provide education on medications.
- Evaluate therapy needs, i.e. occupational, physical, speech, etc.
- Ensure that transportation needs are met
- Ensure community supports are in place post discharge.
- Ensure safety of environment
Member and Family Support
- Assist members of the family and supports with improving the overall health of the member and adherence to the agreed upon plan. Including assistance with paperwork, provision of information and assistance to assess support services.
- Effectively communicate with family and supports.
- Accommodating different cultures, disabilities, languages, race, socio-economic backgrounds, and non-traditional family relationships.
- Identifying which family or supports are capable of receiving information and making decisions.
- Understanding and being able to respond to family dynamics.
Referral to Community Supports and Services
- Identifying available resources, advocating for access to care, assisting in paperwork, and identifying natural supports.
- Engagement with community and social supports.
- Establishing and maintaining relationships with other social support providers.
- Communicating and collaborating with other social support providers.
- Knowledge of eligibility criteria for services.
- Providing or developing resource guides.
- Bachelor s degree with emphasis preferably in social work, psychology, rehabilitation or related field. Equivalent education plus experience will also be considered.
- Prior experience working in a whole person centered program or health care case management preferred.
- Familiarity with mental health theory, emerging promising practices, and Evidence-Based Practice.
- Knowledge of medical and non-medical service delivery system.
- Effective communication with members, family and supports, guardians, and service providers.
- Knowledge of trends and issues, laws and regulations related to the development and delivery of Health Home services and delivery model helpful.
- Ability to establish relationships with individuals and organizations of influence within the social services community, including civic groups, charitable agencies, related government entities, fundraising sources, etc.
- Demonstrated interpersonal and communication skills.