Homeless Complex Care Coordinator - Memorial Health

Provides care management and care coordination services for highly complex clients within the behavioral health setting and across the healthcare continuum, including the community. Provides behavioral health outreach, education, and engagement through health promotion and evidence-based care coordination activities. Works both independently and with multiple teams to manage client engagement and develop a care plan for the client in partnership with behavioral health professionals. Responsible for coordinating care for clients across the continuum, ensuring that the client is receiving the highest level of quality and that all members of the care team are well-informed of the client’s care plan. Responsible for assessing the client’s barriers and adjusting the care plan accordingly to ensure continued engagement.  Embodies the Memorial Health Values of Safety, Integrity, Quality, and Stewardship that support our mission and vision.

Education:

• Bachelor’s degree in social work, counseling or other health and human services field required.  Master’s degree preferred.

Licensure/Certification/Registry:

• CPR certification required or obtained within 30 days of employment.
• Must possess valid Illinois driver’s license and must be deemed as an acceptable driver in accordance with the MHS Fleet Safety Policy (five year MVR will be required).
• Meets the “Mental Health Professional” (MHP) designation as determined by the Department of Human Services MHP required or “Qualified Mental Health Professional” (QMHP) preferred
• Must have or obtain IM+CANS certification within 30 days of hire.

Experience:

• One year minimum experience in social service is required, three years’ experience is preferred.
• One year minimum experience working with diverse populations and individuals with serious mental illness, chronic health conditions, or alcohol and substance abuse is required. Three years’ experience is preferred.
• One year minimum experience with care coordination/management, client engagement, community engagement, and coordination of behavioral health care with complex client populations. 

1. Works with the behavioral health care team to proactively engage clients, individuals, and patients into behavioral healthcare.

1. Manages a client load of high-risk/high utilizer behavioral health clients.

1. Conducts visits with clients or individuals to assess client’s risk, including providing practical assistance to clients to improve their ability to cope within the community within the least restrictive setting possible (for example, assistance may be needed with transportation, budgeting, locating housing, and/or identifying vocational training opportunities).

1. Establishes initial data, including client’s presenting problems, mental status, relevant psychiatric, medical and developmental histories to make decisions regarding diagnosis (per DSM-V) and treatment and/or make appropriate referrals to other treatment sources in the community.

1. Responsible for assisting in the development of a care plan and health goals for high risk clients to reduce their likelihood of over utilization or adverse events.

1. Responsible for partnering with the behavioral health care team and other providers across the continuum to execute on the care plan and assist the client in reaching their health goals.

1. Responsible for coordinating care across the continuum for the assigned client load, including providing care plans to providers as the client accesses services.

1. Responsible for assessing barriers to the care plan or completing the client’s health goals and identifying ways in which to address those barriers.

1. Responsible for managing the on-going engagement of their client load.

1. Responsible for working across multiple sites of care.

1. Must operate effectively with various levels of leadership and clinical expertise.

1. Responsible for maintaining an accurate and complete written record of the assessments, care plan, goals, and all other client interactions.

1. Completes all mandatory education requirements, including monthly clinical supervision as required by the Illinois Department of Human Services.

1. Performs other related work as required or requested.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.