Coordinator Ccbhc Definitive Care

JOB DESCRIPTION General Description

• The mission of Metrocare Services is to serve our neighbors with developmental or mental health challenges by helping them find lives that are meaningful and satisfying. Our vision is that regardless of challenges faced, the people we serve maximize the ability to find the meaning and satisfaction they choose for their lives. Our Center values Integrity, Quality, Diversity, and Perseverance. We are an agency committed to quality, accountability and culturally/gender-responsive, and trauma‑informed care to individuals experiencing serious mental illness, developmental disabilities, and/or co‑occurring disorders.
  
  Metrocare programs focus on the issues that matter most in the lives of the children, families and adults we serve.
• The CCBHC Definitive Care Coordinator will organize access to necessary services and build a therapeutic team to include natural supports and providers for those who are participating in mental health and substance use treatment. The CCBHC Definitive Care Coordinator uses knowledge of social drivers of health, diagnostic characteristics, symptomology of primary mental illness and knowledge of medications, side‑effects and benefits to provide services in a person‑centered, supportive, community‑based environment.
  
  The CCBHC Care Coordinator is primarily responsible for organizing patient care activities and sharing information among all of the participants concerned with an individual in services care to achieve safer and more effective care. This position depends upon successful relationship building with community partners and referral sources to ensure individual in service access to the right care at the right time.
  
  The CCBHC Definitive Care Coordinator is monitored by periodic supervision.

• Create and/or enhance an existing person/family‑centered recovery plan that identifies an individual’s goals, objectives, strengths and preferred involvement of natural supports as well as coordination with internal and external providers.
• Assessing consumer needs on a continual basis throughout the course of treatment.
• Assistance with scheduling and completing all internal and external provider appointments.
• Assistance to meet needs impacting social drivers of health including housing, food, clothing, transportation, employment and academic needs.
• Interacting with other team members to provide comprehensive and timely assistance in resolving issues that are barriers to the consumer receiving services.
• Coordination with internal and external providers to ensure a holistic approach to care that considers all areas of an individual’s life, the individual’s wants and goals and all treatment interventions.
• Documenting services in the electronic health record within 24 hours after services have occurred.
• Contact with individual in service at least one time per every 90 days at minimum.
• Develop/maintain collaborative working relationships with internal and external referral resources; allowing creation/renewal of informal and formal agreements between Metrocare and those external agencies. Relationships with external agencies will include but are not limited to: FQHCs, inpatient psychiatric and substance use facilities, the Department of Veteran Affairs, inpatient acute care hospitals and hospital outpatient clinics and community/regional supports and providers such as schools, child welfare agencies, criminal justice and Indian Health Services.
• Assists the individual in service in developing and/or strengthening natural supports who will participate in care coordination activities.
• Helping to maintain a list of community resources for successful external referrals.
• Maintains confidentiality of information concerning consumers and family members.
• Perform other duties as assigned.

• Ability to assess and organize complex information regarding an individual’s goals in usable format that is clear to the individual and participating members of the therapeutic team (natural supports, internal and external providers).
• Knowledge of Social Drivers of Health and how to assist an individual in service in accessing necessary…