Care Coordinator - Pathways

Lifeline Connections • Vancouver, WA

10d • $21 - $23

About The Position

Lifeline Connections is a community-based behavioral health organization that specializes in providing confidential and compassionate care to individuals who experience substance use and/or mental health conditions. Our Vision - As the premier provider of substance use and mental health services in the Pacific Northwest, we are respected and the most trusted resource for behavioral health treatment and whole-person care. We provide a comprehensive continuum of coordinated quality services, foster enduring relationships, and empower our communities to truly thrive. Our Mission - Through superior customer service, high quality programs, and well-trained and dedicated staff, we inspire hope and support lifesaving changes for people affected by substance use and mental health conditions. POSITION TITLE: Pathways Care Coordinator Non-Exempt Position RESPONSIBLE TO: Recovery Supports Program Director MAJOR DUTIES: This position provides care coordination to agency patients or persons requesting services. Care Coordinators (CC) are designed to utilize the Pathways model to provide support to patients. Care coordinators work one-on-one with patients to help them better self-manage their health through coordination with their providers and education on local resources. In fulfilling these duties, the incumbent performs the following duties independently: Care coordinators will provide outreach and initial Community Needs Assessments resulting in the development of a client profile and initial checklist. Additional health screens can include the Patient Activation or Caregiver Activation Measure (PAM/CAM), Patient Health Questionnaire (PHQ-9) and the KATZ measure for activities of daily living. Other screens may be used as appropriate for care. The patient checklist will be updated at every visit; Supporting the patient in attaining short and long term goals. Motivational interviewing techniques will support goal setting. The CC will spend time advocating, educating and supporting the patient and natural family supports to attain and improved self-management skills; Provide cultural mediation between communities and the healthcare service system, culturally appropriate and accessible health education and information, informal education, counseling and social support and advocacy for individual and community needs; CC’s are a part of and familiar with the communities they live and work with; they are comfortable working in team environments, while building trust with their community members, local service organizations and healthcare providers to build individual and community capacity; As a routine part of working with the Pathways model, the CC, led by the community member, will assess needs and establish a series of Pathways, often requiring referrals to partner organizations that specialize in providing specific health or social services. An essential part of the CC role is to establish solid relationships with key staff people throughout their entire referral network of organizations in order to ensure their ability to follow up on the community members’ status once referred to an external or internal referral partner; The CC, in consult with contact person(s) from referral partner organizations, will use the CCS HUB Connect software to track the number of referrals, both internally and to other external organizations, and assure that the referrals are completed by using Pathways; CC will meet ongoing both in person and telephonically to support patient and the patient attainment of health care goals. Required to complete minimum of one (1) home visit or community visit with participants, every 30 days, considerate to agency’s physical distancing guidelines; Coordinate with the authorizing and health care or social service entities as necessary to maintain self-care and support the patient’s goals; Focus on several key indicators of health, both medical and social, called pathways. Care coordinators support patients in working through specific pathways to ultimately improve their health outcomes; Care Coordinator will document patient progress and recommendations in the Pathways care coordination system. All in person and telephonic encounters will also be documented; Attend HealthConnect monthly meetings and required trainings; Utilize HealthConnect / HUB Connect Software to track referrals; Carry a caseload (As an example, a full-time CHW/Peer could carry a caseload of 40-60 moderate risk community members, or 25 very high-risk individuals). Exact caseload size will be fluid, based on duties assigned and acuity of persons’ served in consultation with Program Director; and Other duties as assigned.

Requirements

• Possess a high school diploma or equivalent and 2 years of experience working in a related field/profession
• Above average Microsoft Office skill set
• Experience working within health systems or providing case management
• Experience with underserved, transient populations
• Unencumbered driver’s license and the ability to become an approved driver per agency policy
• Familiarly in Motivational Interviewing techniques
• Strong communications skills

Nice To Haves

• Associates or Bachelor's degree in a related social service field preferred but not required

Responsibilities

• Care coordinators will provide outreach and initial Community Needs Assessments resulting in the development of a client profile and initial checklist.
• Supporting the patient in attaining short and long term goals.
• Provide cultural mediation between communities and the healthcare service system, culturally appropriate and accessible health education and information, informal education, counseling and social support and advocacy for individual and community needs
• CC’s are a part of and familiar with the communities they live and work with; they are comfortable working in team environments, while building trust with their community members, local service organizations and healthcare providers to build individual and community capacity
• The CC, in consult with contact person(s) from referral partner organizations, will use the CCS HUB Connect software to track the number of referrals, both internally and to other external organizations, and assure that the referrals are completed by using Pathways
• CC will meet ongoing both in person and telephonically to support patient and the patient attainment of health care goals.
• Coordinate with the authorizing and health care or social service entities as necessary to maintain self-care and support the patient’s goals
• Focus on several key indicators of health, both medical and social, called pathways. Care coordinators support patients in working through specific pathways to ultimately improve their health outcomes
• Care Coordinator will document patient progress and recommendations in the Pathways care coordination system. All in person and telephonic encounters will also be documented
• Attend HealthConnect monthly meetings and required trainings
• Utilize HealthConnect / HUB Connect Software to track referrals
• Carry a caseload
• Other duties as assigned.

Benefits

• Lifeline Connections strives to be your employer of choice by offering our regular/full-time employees a generous benefits package. Our plans cover 85% of medical, dental, and vision costs at the employee level and 75% for all dependent plans.
• The majority of out-of-pocket costs (i.e. co-pays, prescriptions, and deductibles) under our medical plans are also covered.
• We also offer other benefits, such as: employer paid Short Term Disability, Long Term Disability, Life Insurance, and supplemental coverage.
• Our full-time employees and some part-time employees also qualify for our 401(K) plan that matches dollar for dollar up to 5%.
• On top of all that, our full-time employees receive approximately 4 weeks of paid time off during their first year of employment (accrual rates increase with years of service), as well as 1 personal holiday and 12 paid holidays per year!
• There are many other supplemental benefits we are glad to offer such as tuition reimbursement and discounted cellular service amongst others.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED