Comunilife Inc. is looking for experienced Care Coordinators to join it Care Coordination Team. The Care Coordinator is responsible for providing care management for clients and their families/support system and advocates for clients to obtain the full range of needed services and ensures coordination of these services. The Care Coordinator promotes linkage development and monitors the effectiveness of linkages with other services providers. The Care Coordinator ensures community follow-up to engage the client in care, promotes compliance with medical appointments, and encourages client self-sufficiency and empowerment.  This position is eligible for Comunilife's benefit package including health insurance, dental, vision, dependent care, paid time off, 401(k), tuition assistance program and more.

Essential Duties:

Reports to assigned Care Coordination Program Director and meets on a weekly basis for supervision or more often if needed.

 Utilizes approved Home Health assessment tool and Health Information Technology (HIT) to prepare initial and ongoing clinical and psychosocial assessments of service needs to identified members.  Identifies level of need and tailors care plan accordingly, reassessing as needed.

Monitors member progress and produces/maintains detailed, accurate and timely documentation of case notes.

Responds to inpatient and ER admission alerts and contacts medical provider/hospitals for admission/discharge information.

Recognizes member as a contributing member of care team through motivational interviewing techniques, continuous transference and reinforcement of self-management skills.

Provides support to member and family, including but not limiting to locating resources to eliminate barriers and advocating on behalf of member and their supports to ensure they have supports necessary to improve their health.

Documents a monthly HML assessment for each assigned member.

Develops resources for referral in all areas needed to assist clients.

Ensures care management team will provide care coordination, appropriate linkages, referrals and follow-up for needed services and supports.

Advocates for necessary services on behalf of the clients.

 Conducts home visits and agency visits as needed and as is outlined in the Care Plan.

Completes Health Risk Assessments, Care Plans, service notes, referrals, linkages, advocacy and follow-up for clients and completes appropriate paperwork associated with such services daily including documentation in all Electronic Medical Records for the corresponding Health Homes.

Works closely with Care Coordination Program Director to assure quality program service delivery and participates in Utilization Review/Quality Improvement process.

Participate in case finding, networking and outreach activities to increase clients’ enrollment.

Works closely with agency’s program directors to ensure assure continuity of care within the organization.