The Care Coordinator is the “link” to ensure a continuity in coordination of client care through their collaborative interaction with all the providers and community relationships involved in that care – including but not limited to – physical health, behavioral health and social service providers. The Care Coordinator provides support to children & families enrolled in the HealthChoice Pathways to Success program through Pillars Community Health. Pathways to Success is a State of Illinois initiative to provide comprehensive care coordination that will enhance access to critical behavioral, medical and social services for children with complex behavioral health challenges.
This position provides coordinated care to participants and facilitates the Child & Family Care Teams through the comprehensive High Fidelity Wrap Around (Evidence Based Practice) services or the Intensive Care Coordination service model. The position will be involved with the oversight and coordination relating to integrated care, development of individualized care planning (IM+CANS), participation in Child and Family Teams, and coordination with case managers and other caregivers.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Undertakes the care coordination in either the High-Fidelity Wraparound or Intensive Care Coordination service delivery model of the Pathways to Success program clients
- Able to meet the training and certification requirements of the High-Fidelity Wraparound evidence-based practice model
- Manages all documentation necessary to maintain organizational and service delivery requirements
- Facilitates Child and Family Team Meetings, as required
- Outreaches and educates participants and their families to the Wrap Around Process and Pathways to Success program
- Manages assigned participant case load through community outreach and by helping to conduct care coordination assessments that identify a child and family’s global needs, strengths, and goals as part of the service plan development. Gathers information for the IM+CANS and related care plans, including social and cultural factors that influence all aspects of health. Conducts visits with child and family in home and community-based settings
- Monitors daily alerts for participants entering an emergency room or inpatient hospital processes and other coordinated care interfaces, following up with clients and facilitating post-discharge appointments.
- Documents the care/service plans and other vital information in electronic health record after each contact and service.
- Actively leads care planning process that specifies direct care resources to meet physical and psychosocial needs; by prioritizing problems and establishing mutually agreed upon goals specific to the client
- Participates as assigned in participant education including development of materials, conducting presentations or supporting other team members in such efforts.
- 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.
- Prepares reports as needed for agency funders relevant to the position.
- Participates in agency meetings and in-services.
- Other duties as assigned.
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 an individual with a disability to perform the essential duties and responsibilities.
EDUCATION AND EXPERIENCE
Bachelor’s degree required, preferably in Human or Health Services or Health Education, or meets the “Mental Health Professional” (MHP) designation as determined by the Department of Human Services. (Link to definition is included below)
Experience working with diverse child and family populations with intensive behavioral health needs, chronic health conditions, or alcohol and substance abuse. Experience completing clinical documentation for a client case load is preferred. Case management experience, while providing care in home or community is also preferred.
- Ability to work as part of a team and collaborate with consumers, referrals sources, and other community providers is essential.
- Ability to relate to a diverse population.
- Excellent written and verbal communication skills.
- Ability to multi-task and meet ongoing deadlines for clinical documentation.
- Experience and proficiency with Outlook and Microsoft office programs, inclusive of Microsoft Teams, is essential.
Bilingual fluency (English/Spanish) required for 1 of the 2 positions.
Must maintain a safe driving record and have current valid Illinois Driver’s License. Personal vehicle needed for transportation to/from home and community-based interventions. Mileage for authorized work-related purposes is reimbursable.
Monday-Friday; 8:30-5, with flexibility to work evenings as client needs determine. 2-3 days of in-person work at either the PCH office or the community to meet with clients.
Pathways to Success Program Definitions:
** Care Coordinators (“CC”) will be trained in both service models and will be designated for either High Fidelity Wraparound or Intensive Care Coordination. CC’s may not mix caseload types and their designation may change during employment based on the referral volume and ongoing interest of children and families in the program.**
Child and Family Team: a team of people important to the child and family that works together closely to create an Individualized Plan of Care. The child and family pick the members of the CFT. It includes formal supports, like service providers, and natural supports such as family members, neighbors, friends, or other community members. The CFT learn about the family’s strengths, needs, and goals. They work together to build an individualized plan of care that will help the child meet their goals. They consider all of the services and supports the family may need, including regular healthy kids services, like check-ups and vaccines, specialist services, medicines/prescription drugs, mental health and substance use services, vision, dental, transportation, local community resources, like utility, childcare, or food assistance
High Fidelity Wraparound is for youth with the most complex needs. These youth typically access crisis services regularly and are often involved in multiple child-serving systems. The Care Coordinators serving youth in the High-Fidelity Wraparound maintain an average caseload of 10 youth. The Child and Family Team meet once per month
Intensive Care Coordination is for youth that would benefit from additional community services, but don’t quite reach the same level of intensity as youth in High Fidelity Wraparound. The Care Coordinators serving youth in Intensive Care Coordination service an average caseload of 25-30 youth. Intensive Home Based Services are intended to be an intensive, short-term service focused on developing the skills necessary to keep the child safe at home.
Mental Health Professional (MHP): https://www.ilga.gov/commission/jcar/admincode/059/059001320A00250R.html
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