The Concerto Care Coordinator is responsible for providing care coordination services by working collaboratively with a team of individuals involved in the care team as they provide medical, behavioral, psycho/social care, health and wellness education, and other related services and supports to Concerto members. Care Coordinators serve as an active advocate for the members’ rights. Plays a key role in the interdisciplinary care team and is a resource to the member, their families, and support systems.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Support an on-going person-centered planning process
- Assist the member to take a lead role in the process and provide information to the member and Integrated Care Team (ICT)
- Assess clinical, social and environmental risk and needs by conducting an assessment process that may include an Health Risk Assessment, Personal Care Assessment, Wavier Assessment, Behavioral Health Assessment, and other assessment tools as appropriate.
- Facilitate timely access to primary care, specialty care, BH, SUD, and I/DD services, medications, and other health services needed by the enrollee, including referrals to address any physical or cognitive barriers
- Facilitate meetings of the Integrated Care Team (ICT), as needed or as requested by the enrollee
- Facilitate communication among the enrollee’s providers, using various methods of communication, which may include electronic health records, secure e-mail, fax, telephone, and written correspondence
- Facilitate direct communication between the provider and the enrollee
- Facilitate enrollee and family education
- Facilitate the enrollee’s evaluation of the process, progress and outcomes
- Identify short term goals, long term goals, barriers to care and facilitate problem resolution
- Advocate with or on behalf of the enrollee as needed, to ensure successful implementation of the Individualized Care Plan
- Support transitions in care when the enrollee moves between care settings
- Engage in other activities or services needed to assist the enrollee in optimizing his or her health status, including assisting with self- management skills or techniques; health education; referrals to support groups, services, and advocacy agencies, as appropriate; and other modalities to improve health status.
- Current licensed Bachelor’s Prepared Social Worker, Limited Licensed Masters Prepared Social Worker, or Licensed Masters Prepared Social Worker.
- Experience with the populations similar to the Enrollee population, including community-based and facility-based people with medical, and/or behavioral needs
- To perform this job successfully, an individual must be able to work proficiently with care management software platform, electronic medical record and similar types of systems
- Case management experience necessary
- Disease management experience useful