Telephonic Care Coordinator

Evergreen Health

The Telephonic Care Coordinator applies the essential activities of case management which include assessment, planning, coordination, monitoring and evaluation with the core components (Comprehensive Case Management, Care Coordination & Health Promotion, Comprehensive Transitional Care, Patient & Family Support and Referral to Community & Social/Support Services) to patients within the Center for Care Coordination. The Telephonic Care Coordinator provides care coordination for patients with a diagnosis of Serious Mental Illness (SPMI), substance use disorder, and other chronic health conditions. The Telephonic Care Coordinator is responsible for the following outcomes: Reduce utilization associated with avoidable and preventable inpatient stays; reduce utilization associated with avoidable emergency room visits; improve outcomes for persons with mental health illness and/or substance use disorders; and improve disease-related care for chronic conditions. The Telephonic Care Coordinator will maintain a larger caseload (55-60 cases). The Telephonic Care Coordinator will be adaptable to change as required due to the fluidity of the patients served.

As part of the Essential Functions for this role, The Telephonic Care Coordinator :

• Delivers core services telephonically in accordance with Health Home standards to patients on assigned caseload. Achieves monthly and quarterly productivity expectations.
• Completes a comprehensive assessment within 60 days of patient’s enrollment and an annual reassessment inclusive of medical, behavioral, social, and rehabilitative needs. Completion of these documents with the patient are to be completed in person with the patient. All other encounters will be telephonic with the exception of when a patient is in crisis. When a patient is in crisis, it is the expectation that the Telephonic Care Coordinator meets with the patient as needed in a face to face capacity
• Completes individualized patient-centered care plan with the patient within 60 days of enrollment and updates monthly to identify patient’s needs and goals, and includes family members and other social supports as appropriate. The Care Plan is also amended at a minimum, annually.
• Completes and amends patient crisis plan. Coordinates with service providers and health plans as appropriate to secure necessary care during a crisis, share crisis intervention and emergency information.
• Coordinates with multidisciplinary team on patient’s care plan, including but not limited to the primary care physician and/or any specialists involved in the treatment plan.
• Links and refers patients to needed services to support care plan including medical and behavioral health care, patient education, entitlement programs, self-help groups, and recovery and self-management.
• Conducts diligent search activities to ensure patient engagement and to assess on-going emerging needs in order to promote continuity of care and improve health outcomes.
• Conducts annual case review with interdisciplinary team to monitor and evaluate patient status.
• Follows up with patient upon notification of ER or inpatient admission and/or discharge and facilities transitions of care within 24-48 hours. Inpatient admissions warrant a higher level of care and will need to be case reviewed with supervisor to transition the patient to a Care Coordinator.
• Advocates for interpretation services and utilizes translation line as needed.
• Maintains complete, current, and accurate patient charts that comply with the Health Home Standards.
• Documents all patient-related encounters and chart activities in a progress note within 24-48 hours, including encounters with patient, providers, and other members of the care team. Attempted contacts and completion of documentation (such as the assessment and care plan) must also be documented in the form of a progress note.
• Enters data timely and accurately to promote patient care delivery and participates in ongoing QI/QA activities and training to improve patient experience and increase data quality where needed. Maintains and protects sensitive information in enterprise systems and uses/shares data in compliance with Information Governance and Security Policies.
• Attends initial orientation, completes required annual trainings, and other trainings to strengthen skills and improve program outcomes.
• Actively checks work emails, reads all company communications and stays up to date with organizational and department specific announcements.
• Adheres to policies regarding working hours, break periods and proper use of the ADP payroll and benefits system.
• Other duties as requested.

Qualified Candidate will have a Bachelor’s degree in health, human or education services and one year of qualifying* experience or Associate’s degree in health, human or education services and one (1) year of qualifying* experience. Qualifying* experience equals professional case management or care coordination experience with the following populations: persons with a chronic illness, and/or persons with a history of mental illness, homelessness, or chemical dependence. Candidate must have a valid NYS Driver’s License and an insured, dependable car.

Job Type: Full-time (Part time may be available)

Required education: Bachelor’s (plus 1 year experience); Associates (plus 2 years experience)

Required experience: Care Coordination/Case Management; Working with clients experiencing chronic illness, homelessness, mental illness and/or chemical dependence

Additional requirements: Must have dependable, insured vehicle and NYS Driver’s License

What Evergreen Health Offers You:

• Remote hybrid schedules may be available for this position
• Opportunities for overtime hours may be available for this position
• Multiple comprehensive medical health insurance plans for you to choose from
• Dental and Vision coverage at no cost to you
• Paid Time Off package that equals 4 weeks of time in your first year
• 403b with a generous company match
• Paid parking or monthly metro pass
• Professional development opportunities
• Paid lunch breaks