Works as part of a multi-disciplinary team and ensures the integration of medical and mental health care for members. Is responsible for working closely with the primary medical provider, the mental health team, and staff of other agencies involved in the members care to proactively manage member care by providing case management, education, care coordination, systems navigation, advocacy and support primarily in-home and/or in the community.
Essential Duties and Responsibilities:
The position is responsible, but not exclusive, for the following:
- Coordinates the delivery of integrated care services to members, in collaboration with clinical and other staff to address the member’s needs.
- Performs integrated healthcare assessment and annual assessment updates.
- Assists in development, implementation and revision of integrated service plans; assures that services provided are specified in the integrated service plan and monitors progress toward treatment goals, crisis plans and coordinating of adult recovery teams.
- Monitors level and intensity of services contained in the members’ individual integrated service plans.
- Assist and support members to follow through on prescribed medical interventions and diagnostic testing.
- Inform and educate members regarding the meaning and implications of test results and prescribed interventions, as per clinic protocol.
- Assesses and addresses barriers to health.
- Obtain records, notes, reports, and consultations from primary, specialty and other providers and ensure that the information is appropriately filed in the electronic health record.
- Consults and cooperates with community systems to facilitate linkage, referral, crisis management, advocacy, and follow up with the focus on attaining treatment goals.
- Provides health literacy and health education groups.
- Offers guidance and education related to members individual needs.
- Provides community and home-based services to members.
- Connects members to resources within CODAC and the community to address identified health concerns.
- Review details and expectations about the referral with
- Provides member advocacy and attends medical appointments, as needed.
- Assists with coordination of scheduling of appointments for members.
- Attends all staff meetings and all other required meetings.
- Maintains member records in accordance with agency and funding source requirements.
- Maintains regular contact with treatment staff to inform and be informed of member’s progress and makes recommendations for continuing care.
- Performs other related duties in accordance with agency growth and changes.
Education & Experience Requirements:
- Masters or Bachelor’s degree in a field related to healthcare and no healthcare related experience OR;
- Masters or Bachelor’s degree in a non-healthcare related field and 1 year of full-time related healthcare experience OR;
- Associates’ degree in a healthcare related field and 2 years of full-time healthcare related experience OR;
- Associate’s degree in a non behavioral or health related field and 2 years full-time healthcare related experience OR;
- High School diploma or General Education Equivalent (GED) and 4 years full-time related healthcare experience.
- Is an Arizona Licensed Registered Nurse OR;
- Is an Arizona Licensed Physician’s Assistant who is not working as a medical practitioner;
- Commission Certified Care Manager (CCCM), a plus.
- Valid Arizona Driver’s license, proof of current insurance and willingness to use personal vehicle. Driver’s license is an essential requirement for performing duties for this position.
- Clean Motor Vehicle Record - no more than 2 moving violations or a license suspension in past 3 years.