Care Coordinator (Accordia Family Medicine)

AltaPointe Health•Mobile, AL

About The Position

The Care Coordinator provides ongoing monitoring and care coordination for consumers on their caseload. They offer care management services to consumers transitioning between levels of care for medical and psychiatric issues. This role assists with meeting reporting requirements for grants and data collection, and advocates for consumers to secure community resources and services. The Care Coordinator collaborates with staff and outside sources to deliver care management services, evaluates and assists with consumer transfer/discharge planning, and provides training on disease management and healthy living skills. They must be able to recognize and deescalate crisis situations, provide psychoeducational services, and assess consumer needs using various approved tools. The role involves identifying and reassessing goals, providing linkage to community resources, and delivering or arranging transportation. The Care Coordinator must demonstrate child and adult specific competencies, including basic knowledge of vital signs, BMI, nutritional status, assistive devices, and recognizing medical emergencies. They will educate consumers on medication adherence, document services rendered, and report any signs of abuse or neglect. The role also includes seeking supervision, maintaining timely, clear, and concise clinical record keeping, and adopting courteous and respectful attitudes towards consumers and coworkers. Administrative duties include participating in performance improvement activities, committees, and completing assigned tasks in a timely manner, while adhering to policies and attending training.

Requirements

Bachelor’s degree in a behavioral health or social services related discipline.
Certification of case management training by Alabama State Department of Mental Health and experience within the Care Management field preferred
Valid verifiable state-issued driver’s license
Knowledge in child and adolescent specialties, outlined below, to be attained within six (6) months of employment:
Knowledge of psychiatric disorders in child and adolescent populations
Knowledge of chronic medical conditions
Basic knowledge of growth and development of child consumers as related to all intellectual, emotional, spiritual, and physical aspects consumer development
Basic knowledge of behavior management and parenting issues
Knowledge of cultural diversity
Knowledge of Trauma Informed Care principles
Knowledge of behavior management, crisis intervention and interventions common to acute psychotic consumers, as well as, to non-violent crisis intervention practices.
Knowledge of educational methods appropriate to the children and adolescents
Knowledge of behavioral health screening tools (PHQ2, PHQ9, CRAFFT, GPRA and certified by the DMH to administer the Child and Adolescent Needs and Strengths (CANS)
Knowledge of social determinants of health
Knowledge of available referral sources for physical health, mental health and social services
Basic knowledge of utilizing Electronic Health Records
Basic knowledge of DMH and Medicaid standards

Responsibilities

Liaison between Accordia-COP, CMHC and/or PCP as appropriate
Provides ongoing monitoring and care coordination for consumers on caseload
Provides care management services to consumers transitioning from more to less restrictive levels of care for medical and psychiatric issues
Assists with meeting reporting requirements of the SAMHSA grant and UDS data
Provides support and advocates on behalf of the consumers in order to secure community resources and needed services
Effectively collaborates and consults with staff members, including clinicians and pharmacists, and outside sources in the delivery and arrangement of care management services
Evaluates and assists in consumer transfer/discharge planning
Provides training on disease management and healthy living skills according to the consumer’s target goals as identified by care plan
Demonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situation
Provides psychoeducational services to patients and families
Demonstrates the ability to assess and reevaluate the consumer needs utilizing the CANS, PHQ2, PHQ9, CRAFFT, GPRA and/or other approved assessments as appropriate
Identifies and reassesses goals and plans for appropriate services utilizing the consumer’s care plan
Provides appropriate linkage to community resources
Delivers or arranges clinically necessary transportation
Effectively demonstrates the application of child and adult specific competencies
Basic knowledge of normal vital signs including temperature, pulse, blood pressure, and respirations
Recognizing and reporting vital signs outside of normal ranges
Recognizing factors that influence temperature, pulse, respirations, and blood pressure
Recognizing normal BMI for consumer’s height and weight
Recognizing changes in nutritional status such recent weight loss or weight gain
Identifying factors that contribute to obesity and chronic health care conditions such as poor diet, inactivity and sedentary lifestyle
Educate consumer on ways to adhere to prescribed diet
Recognizing and reporting changes in the consumers medical and mental status
Basic knowledge of operation of assistive devices such as wheel chairs, canes, and walkers
Recognizing signs and symptoms of emergency medical conditions and when to call 911
Provide education in the maintenance of medications to include recognizing medications and understanding the purpose of medications, possible side effects and what to do when a dose is missed, extra dose taken, or side effects/adverse reaction occur
Provide documentation of services rendered in the appropriate space indicated to include but not limited to consumer problem(s), interventions provided, and consumer response to interventions, referrals, collaboration with other care managers, follow up appointments, case management and community outreach services, etc.
Documentation of assistance with emergency medications and proper reporting
Recognizing signs and symptoms of abuse and neglect and proper reporting
Seeks supervision and consultation as needed
Accepts and employs suggestions for improvement
Actively works to enhance skills
Documents in a timely fashion per AltaPointe policy
Documents in a clear and concise manner.
Documents legibly
Treats consumers with care, dignity and compassion
Respects consumers’ privacy and confidentiality
Is pleasant and cooperative with others
Assists consumers and visitors as needed
Personal values don’t inhibit ability to relate to and care for others
Is sensitive to consumers’ needs, expectations and individual differences
Is gentle and calm with consumers and families
Adopts a team work approach with coworkers
Actively participates in Performance Improvement activities
Actively participates in AltaPointe committees as required
Completes assigned tasks in a timely manner
Follows AltaPointe policies and procedures
Attends appropriate in-services training and other workshops