Care Coordinator- Hope Team

Family & Children's Services•Tulsa, OK

1d•Hybrid

About The Position

Hope Team provides integrated medical and behavioral health care to high risk SMI clients in a community based setting. Position provides advocacy, linkage, referral, individual and group education, resource acquisition services, and care management services to clients in Hope program in a culturally responsive way. Provides a point of contact and work in partnership with Hope staff and partners as part of a multidisciplinary team to provide integrated medical and behavioral health care. Position will provide services in office, in the field, embedded at Crisis Care Center, and tele-behavioral health to adults with mental health, substance use and physical health issues and needs.

Requirements

Requires Bachelor’s degree in social work or equivalent education.
Must obtain Case Management II Certification and Behavioral Health Wellness Coach certification upon hire.
Must possess Driver License and use personal automobile for local travel.
Must transport clients in personal automobile.

Nice To Haves

ODMHSAS CMII certification preferred.

Responsibilities

Provide comprehensive Care Coordination and Case Management services with a special focus on adults.
Services are community and office based.
Coordinate care across the spectrum of health service, including access to high-quality physical (both acute and chronic) and behavioral health care.
Include the client and family members in comprehensive treatment planning. With the adult consumer’s consent, encourage participation of family members and other designated persons in treatment planning and care.
Schedule, coordinate, facilitate weekly treatment team and participate in daily huddles.
Streamline plans of care across the Care Team.
Coordinate care with external health care providers such as pharmacies, PCPs, FQHCs, and DCOs, as well as with behavioral health referrals. Assist consumers and their families with obtaining and keeping referral appointments to outside providers.
Participate in initial treatment plans, strengths and culture preferences, and intakes as needed. Update and modify wrap plans as needed.
Provide individual, family, and/or group services that include screening, coordinating, planning, advocacy, linkage, referral, education, crisis intervention, resource acquisition, and monitoring in a culturally sensitive way.
Track consumers’ admissions and discharges from psychiatric & medical hospitalizations.
Participate in hospital and emergency department discharge processes to transition consumers to a safe community setting according to CCBHC protocols. Ensure timely transfer of medical records, prescriptions, and active follow-up.
For consumers at risk for suicide, coordinate consent and follow-up within 24 hours and implement a continuing plan for suicide prevention and safety and linking to services.
Accompany individuals to medical appointments. Link to non-medical enabling functions and provide assistance with community resources such as housing, social services, education, and employment to facilitate wellness and recovery of the whole person.
Monitor individual health status and service use to determine adherence to or variance from treatment guidelines.
Develop and maintain housing resources for clients experiencing homelessness, including application processes and requirements, document submission, disability application process and submission. May also include outreach to clients in the community