Description of Position

The BH CP Care Coordinator (CC) provides care coordination to identified clients; facilitates the development of a Care Planning Team (CPT); convenes CPT meetings; coordinates and communicates with the members of the CPT to ensure the implementation of the Patient-Centered Treatment Plan (PCTP); works directly with the identified client, his/her primary care and behavioral health providers, and social service providers to implement elements of the PCTP; coordinates the delivery of available services; and monitors and reviews progress toward PCTP goals and updates the PCTP in concert with the CPT. The CC works intensively with Enrollees as the center of accountability for ensuring that services and supports are coordinated across systems and providers. The CC facilitates care planning and coordination which is driven by the needs of Enrollees. IA.

Responsibilities

1. Outreach and engage assigned Enrollees using techniques of Motivational Interviewing.
2. Work collaboratively with client, family, behavioral health providers, and Primary Care Clinicians (PCCs) to complete Comprehensive Assessment (CAs) and with Care Team to complete Patient-Centered Treatment Plans (PCTPs).
3. Ensures that members of the team adopt a strength-based, recovery-oriented approach to the Enrollee in coordinating and delivering services.
4. Follow up with Enrollee, provider, family, social service providers, and natural community supports to ensure PCTP is implemented.
5. Attend discharge planning meetings when Enrollee is at Emergency Department or Inpatient setting.
6. Advocating for the Enrollee's access to services.
7. Facilitate sharing of CA and PCTP and updating as required with members of the care team using available technology and adhering to CCBC, State and Federal policies and regulations.
8. Documenting activity in the CCBC Care Management Electronic Medical Record (EMR) Module.
9. Other duties as defined by agency and/or program leadership.

Requirements

Minimum Bachelor's degree in related field as designated by MBHP, or as waived by CCBC with appropriate human services experience and/or language ability. Must have possession of good organizational skills, plus effective written, verbal and computer skills; experience in navigating client-serving health care delivery systems and experience advocating for Enrollees who are involved with behavioral health systems; and ability to teach Enrollees who are involved with behavioral health systems.

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Date posted: 12/4/2024