Coordinates comprehensive care for vulnerable populations, including those at risk for HIV, by developing individualized care plans and managing patient caseloads. Collaborates with multidisciplinary teams to provide preventive care, community outreach, and navigation of healthcare resources.
Requirements summary
Requires a high school diploma, associate, or bachelor's degree with at least two to six years of experience working with vulnerable populations or Medicaid recipients. Proficiency in computer software and strong communication skills are essential, with bilingual Spanish preferred.
Heartland Alliance Health’s (HAH) mission is to transform healthcare for the most vulnerable – particularly people experiencing homelessness, mental illness or addictions, or struggling with multiple chronic illnesses – improving health for all and the well-being of our community.
This position provides coordinated care to special population participants including those who are at risk for HIV and assists the Care Teams (provider, medical assistant, nurse, behavioral health provider, others) by coordinating care to participants on the provider’s daily schedule and by proactively managing and coordinating care for participants not on the schedule, so as to offer complete preventive care for all participants who are part of the provider’s assigned panel. The position will be involved with the oversight and coordination relating to integrated care, development of individualized care planning, care coordination, case review with Providers, and interacting with Case Managers.
Essential
Duties and Responsibilities
Orients and educates participants and their families by explaining the role of the Care Coordinator, providing Answers and makes appointments for all Health Center Participants, including medical, oral health, case managers, and others.
Manages assigned participant case load through community outreach, conducting care coordination assessments and creation of related care plans, including social and cultural factors that influence health.
Participates in periodic evaluative reviews and/or in-house and external staff training to ensure that he/she understands professional standards and continues to adhere to such standards. Initiates requests for assistance or guidance from Supervisor to address new issues or complex concepts affecting adherence to professional standards.
Assist in routine audits of electronic medical records to ensure completeness of treatment plans
Participates in daily huddles to identify and assist with participants requiring additional services.
Benefits
Dental Insurance
Life Insurance
Paid Holidays
Employee Assistance Program (EAP)
Health Savings Account (HSA)
Vision Insurance
Long-Term Disability Insurance
Educational Assistance
Medical Insurance
Short-Term Disability Insurance
401(k) Retirement Savings Plan
Paid Time Off (PTO)
Tuition Reimbursement
Wellness Programs
Flexible Spending Account (FSA)
Assists in letter and telephone campaigns to participants “lost to care” to re-engage them back to care.
Assists in educating and coaching participants in good healthcare habits.
Provides outreach and engagement to high-risk individuals, provide testing, and provide case management tasks and navigation around PrEP for those who test negative.
Provides HIV testing on-site and through outreach and assist in educating and training the clinical staff to perform the HIV testing.
Monitors daily alerts for participants entering an emergency room or inpatient hospital through Medical Home Network processes and other coordinated care interfaces, following up with participant and making appointments.
Documents treatment plans and other vital information in electronic medical record after visits with participants.
Actively participates in care planning that specifies care coordination by referring to direct care resources to meet physical and psychosocial needs; by prioritizing problems and establishing mutually agreed upon goals specific to the stage of participant activation; by using program planning and group concepts to meet the health needs of the special populations.
Participates as assigned in participant education including development of materials, conducting presentations or supporting other team members in such efforts.
Utilizes experience and training to advocate, mentor, and support other team members (including social workers and community health workers) for accomplishment of overall care coordination goals
Evaluates utilization data at the individual and population health level and uses this to inform the care coordination process.
Collaborates with other multidisciplinary professionals and community agencies to provide a continuum of coordinated care addressing health and related social determinants.
Participates in quality improvement activities as assigned.
Documents comprehensive, accurate, and continual data on client records and program reports.
Collaborates with the health care professionals on behalf of special populations to provide participant health education.
Performs other duties as assigned.
Saturday hours may be necessary on occasion.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education: Bachelor’s degree, Associate degree or High school Diploma.
Experience: At least two years related experience (six years if they don’t have a Bachelor’s) working with vulnerable populations and/or Medicaid recipients required. Previous work in community-based, public health or managed care is preferred.
Other Qualifications: Ability to calmly and politely interact with callers to accurately define their question or concern.
Computer Skills: Demonstrated computer proficiency, including knowledge of word processing, spreadsheet and database software.
Language Skills: Ability to write reports, correspondence, and instructions. Ability to effectively present information and respond to questions from staff, managers, participants, vendors, and the general public. Bilingual Spanish preferred but not required.
Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
Competencies
To perform the job successfully, an individual should demonstrate the following competencies.
Communication: Excellent verbal and written communication skills.
Mathematical: Proficient math and computer skills.
Organizational
Support: Strong organizational skills.
Reasoning: Ability to synthesize information quickly.
Problem solving: Ability to identify and resolve problems in a timely manner.
Gathers and analyses information skillfully and develops alternative solutions
Problem
Solving: Works well in group problem solving situations. Uses reason when dealing with emotional topics.
Motivation: Sets and achieves challenging goals. Demonstrates persistence and overcomes obstacles.
Ethics: Treats people with respect. Keeps commitments. Inspires the respect of others.
Planning/Organizing: Prioritizes and plans work activities. Uses time effectively. Plans for more resources
Professionalism: Approaches others in a tactful manner. Reacts well under pressure. Treats others with respect.
Quality: Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality.
Dependability: Follows instructions, responds to management direction. Takes responsibility for actions.
Benefits
We offer a comprehensive and competitive benefits package designed to support your well-being and professional growth.
Medical, Dental, and Vision Insurance
Health Savings Account (HSA) or Flexible Spending Account (FSA)
Wellness Programs
Employee Assistance Program (EAP)
Tuition Reimbursement and Educational Assistance
401(k) Retirement Savings Plan
Life Insurance
Short-Term and Long-Term Disability Insurance
Paid Time Off (PTO)
Paid Holidays
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee is regularly required to use hands to finger, handle, or feel and reach with hands and arms.
The employee is frequently required to stand; walk; sit and talk or hear.
The employee must occasionally lift and/or move up to 40 pounds.
Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually moderate.
Heartland Alliance Health makes all hiring and employment decisions, and operates all programs, services, and functions without regard to race, receipt of an order of protection, creed, color, age, gender, gender identity, marital or parental status, religion, ancestry, national origin, amnesty, physical or mental disability, protected veterans status, genetic information, sexual orientation, immigrant status, political affiliation or belief, use of FMLA, VESSA, military, and family military rights, ex-offender status (depending on the offense and position to be filled), unfavorable military discharge, membership in an organization whose primary purpose is the protection of civil rights or improvement of living conditions and human relations, height, weight, or HIV infection, in accord with the organization's AIDS Policy Statement of September 1987.
