The Health Homes Care Coordinator works towards achieving the six core care management functions of the designated health home.
Responsible for the overall coordination of services to meet the goals of the child’s comprehensive patient / family focused plan of care with high / medium / low acuity levels.
Builds relationships with the parent / caregiver and child’s care team (physicians, nurses, social workers, etc.) to coordinate and ensure the provision of services.
Assists the parents / caregivers with navigating systems, access issues, and service coordination and empowers them to participate in all aspects of care.
Acts as a liaison to outside agencies and a conduit for the transmission of information between St Mary’s care management and the assigned health home.
Supports St Mary’s mission to provide the highest quality of care management services by complying with regulatory guidelines and meeting agency standards.
JOB DUTIES / RESPONSIBILITIES :
1. Completes the Child and Adolescent Needs Assessment (CANS) to identify child’s medical, social, educational and psychological needs.
Develops a plan of care that is comprehensive of all the child’s identified needs.
2. Initiates and builds relationships with the parent / caregiver / family, designated health home and managed care service providers to coordinate services.
3. Completes all required and necessary visits / contacts to ensure that the child is receiving coordinated services.
4. Works with Managed Medicaid provider and internal supports to ensure Medicaid eligibility and medical provider network enrollment.
5. Participates in team meetings with Health Homes Care Coordination Supervisor to review and implement plan of care.
6. Provides communication to management team on any updates and identified problems and discusses enhanced work process.
7. Initiates and attends team patient care conferences for complex and / or multi-disciplinary patients, whenever needed.
8. Meets all Pediatric Health Homes data entry and documentation requirements.
9 Ensures monthly productivity statistics are in accordance with Health Homes and St Mary’s care management requirements.
10. Participates in all required Health Homes and St Mary’s care management trainings and ongoing assessment tool education.
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