Care Coordinator - UF Health St. Johns Behavioral Health Resource Center, Full-Time Days - UF Health

The Care Coordinator is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and utilization of resources. Conducts home visits, writes individualized care plans, performs SBIRT interventions when necessary, provides direct support to patients: evaluation and assessment of LOC (Level of Care) needs, treatment planning, crisis intervention, individual therapy, and discharge planning to community referrals. Works with a professional team of behavioral health staff to provide excellent care and customer service to patients served. 

• Create care plan and assist post-acute providers in supporting patients’ needs to allow clients to progress to self-management using a multi professional team approach. Modify care plan as needed to best suit patient’s needs and goals. Define and set goals that are patient centered. 
• Manage target population daily census in conjunction with data analysis. Document interventions regularly in required systems for the clinical record and outcome reporting.
• Meet with patients and caregivers/families in their care setting and home. Meet all contract standards defined by regulatory agencies for face to face, telephonic and documentation.
• Identify care plan barriers and work with community partners and clients to identify and move toward appropriate interventions. Engage patient and family, monitor compliance with treatment plan and promote an environment of self-management. Provide support for patient and family issues, resource needs, and refer to community partners as appropriate. Provide evidence based brief solution focused counseling. 
• Develop and implement successful behavior management techniques specific to the patient’s needs. Develop and implement behavioral contracts with clients and families as necessary. 
• Assess adequacy of discharge plan and risk associated with compliance. Provide consultation to post-acute providers re: transition needs and resources for identified barriers. Assess patient’s motivation to change and family resources for support.
• Interact in a collegial and collaborative fashion with ICT team, hospital clinical staff and all community health providers. Contact MD’s with care plan recommendations and changes. Secure orders and refer patient as directed by PCP and/or psychiatrist. 
• Works closely with Care Connect + staff to assess for and address any social determinants of health as well as assessing for any additional barriers to continued treatment. 
• Promote cost effective health care with aligned health system network.
• Completes all tracking logs, scheduling criteria and hand in reports and documents in a timely fashion.
• All other duties as assigned by direct management.

Master's Degree in Social Work, Mental Health Counseling or Marriage & Family Psychology is required.

2 years of Behavioral Health or related experience is required.

BLS, provided by American Heart Association (AHA), required within 30 days of hire. 
Completion of WELLE training (Non-Abusive Psychological & Physical Intervention) within 90-days of employment; annual re-certification will be required thereafter. Must have a good driving record. Valid driver's license and proof of auto insurance required for MVR background check upon hire. Level 2 DCF Background Check required upon hire.