Care Coordinator

POSITION SUMMARY

CareLink NM is a Medicaid-funded care coordination program. CareLink is intended to enhance integration and coordination of primary care, behavioral health care, acute care, and long-term care services for individuals with a serious mental illness diagnosis along with a chronic physical health diagnosis.

CareLink NM services include comprehensive needs assessment and individualized care plan; care coordination; prevention, health promotion, and disease management; comprehensive transitional care; individual and family support service; and referrals to community and social support services.

RESPONSIBILITIES

1. Carry a minimum caseload of 80 individuals at a time.
2. Complete a monthly billable encounter with at least 90% of assigned caseload.
3. Contact eligible individuals to provide education and orientation about CareLink services and obtain and document the individuals’ decisions about opting-in to CareLink.
4. Conduct Comprehensive Needs Assessment (CNA).
5. Create an integrated service plan based on the CNA with the enrolled individual.
6. Create crisis and disaster plans with enrolled individuals.
7. Conduct a minimum of one encounter per month per client that supports the individual’s progress towards service plan goals.
8. Perform all care coordination activities as needed.
9. Maintain clear, concise, and timely documentation adhering to all policies and procedures.
10. Document client interactions and encounters in the GCLC electronic health record, the State of New Mexico’s NMSTAR system, and internal spreadsheets.
11. Maintain all client charts following the CareLink Policy Manual and GCLC requirements.
12. Function as the hub for the individual’s care team developed in collaboration with the individual, their natural supports, and as informed by the CNA.
13. Engage natural supports and community resources to assist in overcoming barriers to engagement or access to care.
14. Engage and collaborate with all integrated care team members and conduct team meetings as necessary to make sure client’s medical and mental health needs are understood by all team members.
15. Understand and maintain HIPAA and 42CFR Part 2 confidentiality standards.
16. Participate in all mental health department training and supervision.
17. Be proficient in all aspects of the CareLink Policy Manual and additional program-related requirements.
18. Perform other duties as assigned.

QUALIFICATIONS

Minimum

1. Bachelor's Degree in Social Work, Education, Counseling, Psychology, Sociology, Criminal Justice, Family Studies, or a related field.
   1. With two years of relevant experience in behavioral healthcare; or
   2. Hold Licensure as Behavioral Health practitioner (e.g. Social Worker, Counselor, Marriage, and Family Therapist); or
   3. Registered Nurse
2. Must pass required background checks and drug screenings.
3. Commitment to the highest ethical standards of the profession.
4. Maintains confidentiality and discretion as a rule.
5. Meets specified deadlines and manages time effectively.
6. Exhibits skills in comprehending, interpreting, and completing delegated tasks efficiently, and ask questions when something is not understood.
7. Self-starter: must have the ability to work independently and follow-up on all work assignments given by the CareLink Supervisor or the Director of Community Services.
8. Ability to multi-task, prioritize and work under pressure without losing sight of objectives.
9. Exemplary organizational skills.
10. Must be computer literate to effectively maintain compliance with all standards and requirements.
11. Professional communication skills in a timely manner (24 hours or less).
    • Respond all emails and correspondence (voice messages, telephone encounters and messages).
12. Keep CareLink Supervisor or the Director of Community Services informed of CLNM member’s changes in both physical and mental health status, urgent issues, and questions about confidentiality.
13. Maintain a valid and unrestricted NM Driver’s License.
14. Must be able to use personal vehicle over course of employment.
15. Maintain valid and sufficient personal automobile insurance.

Preferred

1. Previous work providing in-home or community-based mental health or case management services.
2. Experience with medically integrated mental health services.
3. Demonstrated interest in rural and community health.
4. Fluency in English and Spanish, both verbal and written.