OBJECTIVE/OVERVIEW CUHCC’s mission is to seek health equity in our community by advancing the well-being of diverse people. The clinic is known for providing high quality care to diverse patients and is moving forward in improving timely access to care for patients. This position contributes to the efficiency and effectiveness of the clinic’s services by providing care coordination efforts for adults, children and families which also includes access to services and skills training to people experiencing high risk and complicated physical and/or mental health issues. This position provides care coordination services for patients of the clinic and enrolled in Health Care Home (HCH), using an approach that is culturally tailored and supports the patient’s recovery, improved functioning, development of skills, and management of chronic health conditions and social determinants of health.
REPORTING RELATIONSHIPS This position reports to Care Coordination Manager.
ESSENTIAL FUNCTIONS & PERCENTAGE FOR EACH FUNCTION:
1. Provide Care Coordination services to patients with mental health diagnosis: 90% • Follow HCH procedure including, but not limited to, patient contact requirements, documentation requirements, and panel management approach • Identify eligible patients for services consistent with procedure • Provide diligent outreach and engagement strategies for patients • Provide optimal access to services (e.g. attend to referrals in a timely manner) • Data entry and management of patient registry for all assigned patients (e.g. intake/psychosocial assessment/health care plan completion dates, community referrals, internal/external care team, etc.) • Provide support to patients with mental health concerns (e.g psychoeducation, brief counseling, risk assessment and safety planning, and connecting to longer-term mental health services when needed) • Complete health care plan, with individualized health goals, for each patient within 90 days of enrollment • Coordinate patient’s care (e.g. schedule appointments, assist patient in preparing for appointments, provide appointment reminders, attend appointments with the patient when needed, make follow-up calls to patients when needed between appointments and/or provide no-show follow-up calls if requested by provider) • Coordinate with patient’s care team, including internal and external providers as well as patient’s family or identified supports (e.g. providing updates about changes, health care needs or concerns, ensuring continuity of care, completing necessary paperwork to access care) • For all care coordination patients assigned, serve as the point person for patient’s care within the clinic promoting integrated care • Provide coaching to patient and their identified supports on their conditions and diagnosis • Consult with supervisor for questions such as maintaining scope of practice, ethical considerations, and/or identifying needed resources to support patient’s goals • Schedule, facilitate, and coordinate Care Team Consults with patient’s care team
2. Other 10% • Attend all staff meeting • Complete appropriate training as required • Participate in team consultation meetings • Participate in weekly individual supervision • Participate in weekly team meetings • Participate in strategic planning, site visits, and evaluation • Participate in quality improvements efforts • Create resource lists that complement patient needs • Build community partnerships • Other duties as assigned
*CUHCC reserves the right to change or add duties to this position consistent with the job classification.
All required qualifications must be documented on application materials.
1) BA/BS in one of the behavioral sciences or related fields including but not limited to social work, psychology, or nursing from an accredited college or university with at least two years of experience in the delivery of services to persons with mental illness or a combination of related education and work experience to equal six years.
2) Fully bilingual in Somali; needs to pass proficiency test.
1. Master’s or other graduate degree in one of the behavioral sciences or related fields from an accredited college or university and post-master’s experience in the treatment of mental illness. 2. Knowledge and interest in serving patients with mental, medical, dental, sexual, and chemical health needs 3. Experience in managing clinical care using an electronic health record 4. Knowledge of community resources and/or social service agencies 5. Experience in providing care coordination to a complex, diverse population 6. Experience working with children and adults
a. Strong project management skills, analytical aptitude and problem solving skills b. Strong time management and organizational skills c. Excellent verbal and written communication skills d. Customer service knowledge and skills e. Ability to de-escalate mental health crisis situations f. Proficiency in utilizing an electronic medical record, registries or databases g. Capacity to effectively communicate in challenging clinical situations h. Excellent documentation skills i. Professional demeanor with patients and colleagues
Internal Number: 335502
About University of Minnesota, Twin Cities
The University of Minnesota, founded in the belief that all people are enriched by understanding, is dedicated to the advancement of learning and the search for truth; to the sharing of this knowledge through education for a diverse community; and to the application of this knowledge to benefit the people of the state, the nation, and the world.