Care Coordinator

Holy-Cross-Medical-Center; Taos (NM); On-site; USD 42,000 - 64,000; Full time

Job summary

Holy-Cross-Medical-Center is seeking a dedicated Care Coordinator to support perinatal clients in clinics, homes, and community settings. You will implement HRA, CNA, CCP and SMART goals, assess needs, and arrange referrals to ensure access to services and improved outcomes.

You will engage with providers, assist with telehealth setup, and maintain a 32-40 client caseload while upholding confidentiality and HIPAA standards.

Qualifications

• Knowledge of maternal/child health issues.
• Knowledge of and shared lived experience with the community served.
• Client-centered, empathic, strengths-based, health-literate, trauma-informed care.
• Evidence-based behavior change fundamentals to support client goals.
• Understanding of social determinants of health and health equity.
• Knowledge of home telehealth technology setup and usage.
• Knowledge of online data collection and reporting.
• Outreach, partnerships, and referral management.
• Ability to follow Care Coordination model to full fidelity.
• Two+ years in social services or health care preferred.

Responsibilities

• Meets perinatal clients in clinics, hospitals, homes, or community settings.
• Enrolls and engages clients in Care Coordination with HRA, CNA, CCP and SMART goals.
• Assesses social, material, and healthcare needs to develop a comprehensive care plan.
• Explains benefits of referrals and eligibility criteria.
• Conducts outreach to providers to build partnerships.
• Encourages participation in home visiting, classes, breastfeeding support, and advance directives.
• Follows up on referrals to confirm receipt and insurance coverage, and aids with logistics.
• Builds trusted partnerships with clients, providers, and supports.
• Assists with telehealth setup and helps enroll in programs.
• Maintains a caseload of 32-40 active clients and documents progress.
• Implements Care Coordination with fidelity and reports data accurately.
• Participates in team meetings, trainings, and quality improvement activities.
• Seeks NM DOH CHW certification within one year if asked.
• Collaborates with supervisors, auditors, payors, and billing to ensure contracting.

Skills

Maternal/child health

Community knowledge

Client-centered care

Behavior change

Social determinants of health

Home telehealth

Data collection

Outreach & referrals

Care Coordination

Job description

• Experience in social services, healthcare, or related field

Education:

Mandatory Knowledge, Skills, Abilities and Other Qualifications:

• Knowledge of maternal/child health issues.
• Knowledge of and shared lived experience with the community served.
• Competence in widely agreed-upon principles of client-centered practice: empathic, strengths-based, health-literate, trauma-informed, stigma-free care and services.
• Understands fundamentals of evidence-based behavior change, and can support and build on client needs, goals, strengths, and abilities to work towards goals.
• Is fluent in how social determinants of health shape health and health equity, as well as the relationship of health to social justice.
• Knowledge of technology and ability to assist clients with home telehealth technology.
• Knowledge of detailed data collection and reporting in on-line data base.
• Knowledge of outreach, developing partnership, and referral management.
• Ability to follow a perscrpitive Care Coordination model to full fidelity.

Preferred qualifications

• Two or more years experience in social service field or relevant health care setting.

essential Duties, functions & Responsibilities

• Meets with perinatal clients and children in a variety of settings including: medical clinics, hospitals, client homes and community settings based on client preference.
• Enrolls and engages perinatal clients and children in a Care Coordination model that includes: Health Risk Assessment (HRA), Comprehensive Needs Assessment (CNA) and related Comprehensive Care Plan (CCP) that supports client access to needed services and implements client centered SMART (Specific, Measureable, Achievable, Realistic, and Timely) goals.
• Conducts assessment of social, material, and healthcare needs to collaboratively with the client develop a referral and Comprehensive Care Plan that identifies priorities, lists and tracks client SMART goals, and assist clients in overcoming barriers to health and well being.
• Has knowledge of and explains the benefits of available social service and medical referrals, services, programs and client eligibility criteria.
• Conducts outreach to medical and social service providers to create new partnerships that benefit patients and the Care Coordination program.
• Encourages the client to participate in perinatal home visiting programs, partening education classes, breastfeeding support, setting up Advance Directivies, Disater Prepardness Plans and other social service and medical referrals.
• Follows up on client referrals to: confirm referral was received, that the patients insurance covers the referred practitioner, and assists the patient with hotel, transportation, child care, or other barriers to her attending in-person appointments.
• Builds a trusting partnership with clients, medical providers, social service providers, and other social supports.
• Supports patients in creative ways including: being a support person upon patient or medical team request, attending Labor and Delivery if needed, accompanying the patient at other medical, social service, or behavioral health appointments, and completes, submits and manages Medicaid (or other) transportation and lodging requests for patients.
• Assists patients with home telehealth technology set up and usage including: helping patients enroll in necessary programs/applications, connecting, testing troubleshooting and getting help as needed for home telehealth communication and reporting.
• Maintains a required caseload of 32-40 active clients.
• Implements and documents the Care Coordination model to full fidelity.
• Displays openness and implements feedback as directed by supervisor, Care Coordination auditors, and insurance billing department.
• Follows policies and procedures to collect and report required patient data and in implementing the Care Coordination model to fidelity.
• Is comfortable with detailed reporting and using a computer to input client data during client meetings.
• Is comfortable asking personal questions and working with diverse clients.
• Provides stigma-free, trauma-informed, health literate, and culturally/linguistically/developmentally appropriate care and services to clients and their children.
• Maintains confidentiality of medical records and personal information in compliance with HIPAA, both electronic and paper records.
• Identifies risk factors and safety issues and educates, informs and intervenes as necessary following guidelines and protocol of medical or social service providers, including reporting abuse and neglect.
• Actively participates in clinical team meetings, case conferences, trainings, networks, grand rounds, continuing education, and conferences to maintain or improve quality services and delivery systems.
• Is committed to becoming certified as a NM Department of Health Community Health Worker within one year of hired if asked to do so.
• Work with supervisor, auditors, payors, clinics, and billing departments to ensure that Care Coordination is contracted for and billed to insurance/Medicaid.