Job Details

SUMMARY: The role of the Care Coordinator is to enhance the quality of patient safety, engagement and satisfaction. To promote continuity of care and cost effectiveness through the integration and functions of care management. The Care Coordinator analyzes data, monitors specific datapoints and acts upon them to ensure patient safety. This position acts as the patient and program liaison to internal services and external community partners and payors.

ESSENTIAL RESPONSIBILITIES AND TASKS:

• Collect and manage patient and program data as needed for tracking and evaluating purposes.
• For patients within the first 90 days of enrollment, track completion of the treatment initiation process implementing interventions as needed to ensure the completion of these requirements.
• If part of the Intake and Stabilization Care Team; act as a panel manager for the Medication First Track patients; preparing utilization review and recommendations, monitoring urine drug screen results, dose reductions, missed doses etc...
• Act as the point of contact for Jails, SNFs, and other community partners providing coordination of medication pick up while the patient is in their care.
• Assumes lead role in proactive outreach to patients through daily outreach calls and/or sending letters to schedule appointments or coordinate referrals.
• Assists Panel Manager to scrub the panel daily to identify which patients need immediate attention and assist the team in developing a plan.
• Establish and maintain effective working relationships with team and external providers. Assist medical and clinical staff in preparing and implementing care recommendations.
• Coordinate, track and document patient referrals to external partners when patient needs are identified e.g.; primary care, mental health counseling, housing and employment services.
• Participate in interdisciplinary staffing, huddles and conferences to review treatment goals, medication recommendations, optimize resource utilization, and identify patient needs.
• Analyze specific data points as prescribed by patient's length of medication order and prepare summary for treatment team meetings. This will include urine drug screen results, missed doses, concerns identified by medical staff etc.
• Conduct review for appropriate utilization of services from admission through discharge evaluating patient safety, level of care and quality of care provided.
• Provide utilization and continued care updates to community and managed care providers.
• Works with Panel Manager to aggregate, analyze and develop dashboards integrating the data and prioritizing initiatives to enhance patient care and CCO Outcome Metrics.
• Provide timely, accurate and complete documentation in the electronic medical record.
• Ensure compliance with quality patient care and regulations outline by OARS, Joint Commission, SAMHSA, and other certifying bodies.
• Demonstrate effective clinical and professional judgement to support safe and quality treatment.
• Maintain credentialing and adherence to ethical guidelines.
• Actively participate in supervision and professional development.

• Achieve outcomes using methods that align with CODA's mission and values:
  • Communicate accurately and positively about early recovery and the use of evidence-based treatments.
  • Use data and science to identify barriers, overcome obstacles, and inform decisions.
  • Be financially responsible; avoid waste, document accurately, seek new opportunities to serve.
  • Demonstrate compassion and respect for others.

• Train and/or mentor other team members as assigned.
• Provide outreach and education to community partners as assigned.
• May be required to travel between locations (if an approved driver).
• Consistent attendance and punctuality are required of this position.

SECONDARY RESPONSIBILITIES AND TASKS:

• Participate in special projects and trainings as assigned.
• Assist with short-term coverage for additional clinical and administrative duties where needed.

SUPERVISORY RESPONSIBILITIES:

This position does not have supervisory responsibilities.

REQUIRED EDUCATION, EXPERIENCE:

• Preferred minimum of 2 years experience in care management, healthcare environment, discharge planning, and social services.
• Bachelor's degree in Social Work or related field.
• Advanced knowledge of and ability to effectively navigate a complex network of community resources and patient engagement.

COMPETENCIES AND SKILLS:

• Ability to maintain professional communications and boundaries while managing complex situations and interacting with individuals diagnosed with substance use or co-occurring conditions.
• Ability to utilize both oral and written communications skills to effectively communicate with patients, co-workers, community resources, supervisors, and various other individuals encountered in the course of performing work while maintaining patient confidentiality and establishing professional rapport.)
• Ability to operate a computer, utilize basic MS Office programs, and effectively navigate and maintain patient records in an electronic medical records system.
• Possess a high level of organizational skills with the capacity to define, collect, maintain and summarize data.

REQUIRED CERTIFICATIONS AND LICENSES:

• Ability to attain CADC I or above or credentialed within 24 months of employment (would require CADC-R within 30 days minimum).

-OR-

• Certified Recovery Mentor or Peer Support Specialist certification with 1 year of paid experience in social or behavioral health services experience.
• May be required to attain a Basic Life Support (BLS) certification or ability to acquire within 90 days of hire.
• Crisis prevention training completion within 90 days of hire.
• May need current Oregon or Washington Driver's License.

PHYSICAL DEMANDS:

• Must be able to safely operate a motor vehicle if required to drive.
• Must be able to perform Basic Life Support for 15 minutes continuously if certified in BLS.
• Must be able to occasionally lift up to 25 lbs.
• Must be able to follow proper protocol while interacting directly with patients and working in a clinical environment.
• Must be able to operate a personal computer, including reading from a computer monitor, keyboarding, and using a mouse.
• Must be able to negotiate staircase, reach, bend, and handle objects.

OTHER REQUIREMENTS:

§ A negative result on all pre-employment, reasonable suspicion, and post accident drug screens.

§ An acceptable criminal record as determined by DHS, the Oregon Administrative Rules, and the Oregon Revised Statutes

§ An acceptable driving record and insurance coverage as recommended by CODA's automobile insurance provider if required to drive.