Service/Care Coordinator

JOB SUMMARY

In partnership with Rocky Mountain Health Plans/United (RMHP/U), as the regional accountable entity for Medicaid, this position serves as the RMHP/U Care Coordinator for clients served by the Grand Junction Housing Authority (GJHA).   Combining the two roles to maximize GJHA staff’s ability to provide assistance to clients as they navigate community and health care services.  This position acts as a community liaison and a client advocate by coordinating linkages or referrals to improve health, social, and environmental conditions for clients. This position assumes responsibility for case management function within the assigned facility.  This function includes contacting service providers and agencies for client referrals and the ongoing case management responsibility.  This position educates clients on available services and monitors provisions of service, in conjunction with community providers.

ESSENTIAL JOB FUNCTIONS - SERVICE COORDINATOR

• Assists and advises clients and families of the services which may be necessary to maintain a self-reliant lifestyle.
• Promotes wellness activities for all clients.
• Educates clients, families and staff on available community resources.
• Assists clients in building informal support networks among themselves and with family clients.
• Acts as a liaison between community agencies, service providers, and clients.
• Encourages clients to be proactive in meeting their social and physical needs.
• Facilitates meeting of needs when necessary but avoids the creation of unhealthy dependence.
• Uses the least drastic intervention necessary to alleviate a problem situation.
• Assists clients to understand lease and tenancy obligations.
• Must ensure all meetings with clients are highly confidential.      If there is a fear of a safety issue regarding another staff person or clients, the Service Coordinator must report the concern to the Supervisor immediately and follow proper procedures.
• Monitors the delivery of services to clients to ensure they are appropriate, timely, and satisfactory.  May also manage such services when appropriate.
• Performs service management function for all clients requesting assistance.
• Provides case management (i.e.: evaluation of social and physical needs), will develop a service plan for each client when such service is not being provided by the general service community.
• Educates clients on service availability, application procedures, clients’ rights, etc., both individually and as a group.
• Reports all suspected abuse situations to the appropriate agency.
• Sets up volunteer support programs with service organizations in the community.
• Advocates and may negotiate on behalf of clients for adequate, timely and cost-effective provision of services.
• Meets with service providers as needed and appropriate.
• Assembles a directory of community services and makes it available to clients.
• Helps with physical needs such as obtaining durable medical equipment

ESSENTIAL JOB FUNCTIONS – CARE COORDINATOR

Maintains client confidentiality and receives HIPAA compliance training from Rocky Mountain Health Plans. Care Coordinator uses only the minimum amount of protected health information (PHI) necessary to accomplish job related responsibilities. 

•  Accompany clients to medical appointments when needed.  Transportation will be in a GJHA vehicle.

• Conducting client assessments.

  • Assessing the changing needs and condition of the client and communicate this information to all involved Care Coordinators, community partners, physician and other appropriate individuals, according to shared policies and procedures.

  • Meet departmental standards and deadlines for timely completion of all required documentation. 

• Educating clients about behaviors that can enhance their health and assist clients with navigating the health system.

• Outreach to clients who have been discharged from a client stay or from an Emergency Department, according to departmental policies and procedures.

• Following up with clients within 48 hours of discharge from Physical or Behavioral Health facility, Skilled Nursing Facility, Rehabilitative Stay or other Long-Term Care Facility.

• Providing assistance during care transitions from hospitals or other care institutions to home- or community-based settings or during other transitions, such as the transition from children’s health services to adult health services or from hospital or home care to care in a nursing facility.

• Promoting continuity of care and prevention of unnecessary re-hospitalizations. Documenting and communicating necessary information about the Client to the providers, institutions and individuals involved with the Client.

• Conducting screeners to identify client needs and scheduling home visits to complete Comprehensive Assessment with clients.

• Engaging difficult to reach and non-compliant clients, which at times involves outreach at locations and facilities that clients may frequent.

• Develop an individualized care plan together with clients who have identified needs and goals.  Ensure that these care plans are appropriate for client needs and culturally sensitive.  Work together with clients to meet these goals.

• Communicate client issues requiring interventions to appropriate departments and providers.

• Comply with guidelines set forth by Colorado Health Care Policy and Finance (HCPF).

• The ability to participate in and/or facilitate interdisciplinary team meetings      with RMHP/U.

• Participate in staff meetings, case conferences and in-services. Remain knowledgeable of all policies and procedures that impact decisions and care. 

• This position requires travel between various locations and timely arrival and departure from various locations. The employee must meet the requirements for Colorado licensure and company requirements for liability insurance coverage. 

ADDITIONAL JOB FUNCTIONS 

• Treats people with respect and work with integrity and professional ethics, upholding the agency’s value and mission. Represents the agency in a positive, professional and ethical manner at all times. This specifically includes abiding by all of the ethical rules outlined in the Employee Handbook.
• Attend scheduled meetings with Supportive Services Supervisor and other supportive service staff to discuss various items of concern and/or interest of both parties.
• Maintains the utmost confidentiality of all applicant and clients information.
• Must be a team player and act at all times in a manner that is in the best interest of the GJHA and Rocky Mountain Health Plans.
• Uses a time management system and other organizational tools set up by the GJHA to organize tasks and manage time effectively.
• Responsible to maintain desk in a neat and clean manner. No information relating to applicants and clients, including files and computer screens, should be visible to office visitors or left on the desk after work hours.
• Must have the ability to work independently in a shared work environment.
• Minimal of out-of-town travel is required for occasional training seminars.
• Minimal evening or weekend work time required.

• Makes rational and appropriate decisions. Communicates clearly and professionally verbally and in writing.

• Maintains the utmost confidentiality of all applicant and client information. 

• The Service Coordinator is NOT PERMITTED at any time to handle the client’s medication.  The Service Coordinator is NOT to provide support services directly or assist with other administrative work normally associated with assigned property.  Additionally, the role is NOT one of an activity director; however, education programming that empowers and enhances clients independence is appropriate.  The Service Coordinator cannot provide transportation in her/his personal vehicle.  The Service Coordinator will not provide home health care services (i.e.:  clean apartment, cook meals, administer medications, assist with bathing, apply medical dressings, etc.).
• The Service/Care Coordinator works closely with the Lead Service/Care Coordinator for direction of services.

MINIMUM QUALIFICATIONS/SKILLS NEEDED

• A Bachelor’s degree of Social Work or Degree in Gerontology, Psychology or Counseling is preferable.  However, individuals without a degree, but with 2 – 3 years of appropriate work experience will be considered.

• As an employee of a vendor who may enter any U.S. UnitedHealth Group or affiliate site, it is required to be fully vaccinated against COVID-19.

• Demonstrates working knowledge of community services in the region with particular knowledge of services that are provided to the elderly and disabled.
• Knowledge in the aging process, elder services, disability services, drug and alcohol abuse and mental health issues.
• Aware of eligibility for and procedures of federal and state entitlement programs.
• Alert to legal liability issues relating to providing service coordination.
• Requires a valid Colorado Drivers License and the ability to be insured at standard rates.
• Criminal background checks are required and a pre-placement physical may be required.