Care Coordinator I-Community Health Worker

Participant of the Interdisciplinary Care Plan team, to ensure appropriate interventions, cost effective delivery of quality care and services across the continuum. Assesses and reviews plan of care regularly to identify gaps in care, trends to improve health and quality of life outcomes; collects clinical path variance data that indicates potential areas for improvement of case and services provided; works with members and the interdisciplinary care plan team to adjust plan of care, when necessary. Provides care coordination to members with stable chronic condition and /r with those whose care requires coordination for some period of time. Develops and communicates plan for authorization of services, and serves as point of contact to ensure services are rendered appropriately, (i.e. during transition to home care, back up plans, community based services). Conducts health risk assessment and/or comprehensive needs assessment which includes, but is not limited to psycho-social, physical, medical, behavioral, environmental, and financial parameters under the supervision of a licensed professional. Implements, coordinates, and monitors strategies for members and families to improve health and quality of life outcomes. Develops, documents and implements plan which provides appropriate resources to address social, physical, mental, emotional, spiritual and supportive needs. Acts as an advocate for members care needs by identifying and addressing gaps in care. Performs ongoing monitoring of the plan of care to evaluate effectiveness. Measures the effectiveness of interventions as identified in the members care plan. Duties performed under the supervision of a licensed professional. Conducts face to face home visits, as required. Facilitates a team approach to the coordination and cost effective delivery to quality care and services. Educates providers, support staff, members and families regarding care coordination role and health strategies with a focus on member-focused approach to care. Provides assistance to members with questions and concerns regarding care, providers or delivery system. Maintains professional relationship with external stakeholders, such as inpatient, outpatient and community resources. Assists with orientation and mentoring of new team members as appropriate. Performs other functions as required.