This position is hybrid-remote and will require occasional work shifts in the office setting. 

The Care Coordinator is responsible for ensuring linkages for CCBHC patients and the community to provide seamless transitions across the health services spectrum. This includes physical and behavioral health, community services (i.e., social services, housing, educational systems, employment services, and other needed services) as needed to facilitate wellness and recovery of the whole person, based on a person-centered plan of care, as required by CCBHC. The Care Coordinator will work collaboratively with clinical and non-clinical staff, external providers, and community resources to assist clients in overcoming barriers to care, improving health outcomes, and promoting overall well-being. The Care Coordinator must be patient-focused, detail oriented, well organized, and proficient in management of patient electronic health records. The role requires strong communication and problem-solving skills.

General Responsibilities:

• Assess and re-evaluate patient needs utilizing information from EHR and additional tools as appropriate to determine patient needs and preferences and communicate those to all treatment participants
• Create an Integrated Care Plan in conjunction with the patient and/or caregiver
• Ensure the patient understands the Care Plan and is equipped to follow it
• Identify and address all barriers that might impede the ability of the patient to care for themselves
• Assemble appropriate team of professionals to assist in meeting patient needs, organize patient care activities and share information among all participants
• Assist the patient/caretaker in navigating the health system while addressing any insurance coverage issues
• Update assessment and care plan at least every 90 days
• Utilize the Integrated Care Plan to drive all activities and services
• Provide information and feedback in daily Huddles regarding needs, plans/interventions/results
• Research ways to meet needs and put action steps in place, monitor for progress
• Advocate on behalf of the patient
• Follow up regularly with patient to ensure needs are being met and identify any changes to patient circumstances, any compliance concerns
• Consult with treatment team when noncompliance is found
• Provide training on disease management and healthy living skills
• Provides initial Diabetes Care Introduction
• Provide support and education for patient and their support system
• Facilitate securing/providing medical records when patient is in the hospital, ED, etc.
• Track and support patients when they obtain services outside the practice.
• Follow-up with patients within a few days of an emergency room visit or hospital discharge.
• Communicate test results and care plans to patients/families.
• Collaborate and consult with staff members and outside sources in the delivery and arrangement of services
• Demonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situation
• Effectively demonstrates the application of adult specific competencies

Supervision and Consultation:

• Seek supervision and consultation as needed
• Accept and employs suggestions for improvement
• Actively works to enhance skills

Clinical Record Keeping:

• Document in a timely fashion per AltaPointe policy
• Document in a clear and concise manner.
• Document legibly

Courteous and respectful attitudes towards consumers, visitors, and co-workers:

• Treat patients with care, dignity, and respect
• Respect privacy and confidentiality
• Assist others as needed
• Adopt a teamwork approach with coworkers

Administrative and Other Related Duties as Assigned:

• Actively participates in Performance Improvement activities
• Actively participates in AltaPointe committees as required
• Completes assigned tasks in a timely manner
• Follows AltaPointe policies and procedures
• Attends appropriate in-services training and other workshops

Alabama Licensed Practical Nurse (LPN) in good standing, three years’ experience in nursing is required. Experience working with and accessing community resources; Proficiency in accurate and timely documentation of care coordination in the electronic health record; Demonstrated ability to work with multi-disciplinary teams; Prior work with the special populations as required by CCBHC, preferred.  Proficiency in managing multiple priorities.