Patient Care Coordinator with 2+ years of experience in providing exceptional customer service and delivering quality care. Skilled in creating individualized care plans and collaborating with multidisciplinary teams.
§ Work with the population served by the Health Homes Program, which includes adults living with a serious mental illness, adults with chronic medical conditions, and/or individuals with a history of alcoholism and/or substance use disorders.
§ Conduct initial assessments and reassessments of members’ needs, including medical, mental health, substance use, financial, housing, and support needs; develop person-centered care plans with documented input and approval from other providers and the member in adherence with Health Home standards.
§ Work with member’s medical and behavioral health staff to develop, implement, and coordinate the care plan for clients with chronic illnesses, such as diabetes, asthma, congestive heart failure, hypertension, behavioral health conditions, and HIV, among other illnesses, based on the Health Home chronic disease care coordination model standards.
§ Coordinate member services with all service providers through regular case conferencing in accordance with Health Home guidelines
§ Conduct field visits to individuals in their homes or locations of their choice to provide services.