PRIMARY FUNCTION: Coordinating care and providing guidance to clients with complex psychiatric and/or co-morbid medical conditions. Develops effective interpersonal relationships with clients and works collaboratively with the interdisciplinary care team to improve health outcomes. Utilizes internal and community resources to educate clients and form a care plan with specific health outcomes.
DUTIES & RESPONSIBILITIES:
• Works collaboratively to ensure thorough and timely monitoring of up to 60 clients and their progress toward
Care Plan goals.
• Reviews Care Plan and confirms intensity level of identified client to ensure service needs are met.
• Interacts with client and client caregivers to ensure continuity of care, patient adherence to care plans, and
identifications of barriers preventing adherence to care plan.
• Tracks all medical, behavioral substance use and other network referrals made for clients and ensures clients
follow up on referrals and attend scheduled appointments, through accompaniment when necessary.
• Provides phone and physical outreach to clients who have been non-adherent to necessary treatment
appointments or have missed appointments for initial visits with new providers. Makes reminder phone calls to
patients for all appointments.
• Provides outreach via phone to clients to ensure appropriate follow up regarding self-care, medication refills,
Care Plan adherence, scheduled office visits, test results/lab work, and all other pertinent psycho-social issues.
• Ensures that relevant care team members receive important client alerts, including ER visits, hospitalization
admission/discharge information and other urgent care notifications.
• Tracks/monitors client progress through a combination of written work, agency databases, health home data
system and case conferences with the Care Team. Documents and maintains case records in agency database
and completes all data entry in a timely fashion.
• Becomes familiarized with service providers in the Health Home network and maintains a comprehensive list of
contact information for key personnel within the network. Always represents The Alliance with the highest level
of professionalism and respect.
• Monitors client entitlements, insurance, and other benefits to ensure they remain active and in place. Assists
with reinstatement of said benefits.
• Participates in initial and ongoing trainings as necessary to maintain a level of knowledge related to serious
physical ailments as defined by Health Home regulations.
• Performs other duties as required.
• Attend a minimum of two agency events for clients and one agency fundraising event every 12-month period.