Care Coordinator (Behavioral Health/Substance Use)

North Star Health, an independent Federally Qualified Health Center comprised of multiple Patient-Centered Medical Home practices delivering team-based care in Southern VT and Southwestern New Hampshire, is seeking a Behavioral Health/Substance Use Care Coordinator. In this role, you will work with the primary care team and BH/SU providers to manage transitions of care, access services, and support treatment in line with the care plan developed with the patient.

In this role you will:

• Promote and work to achieve our mission and vision to connect with and care for our community so everyone may enjoy health and wellness.
• Receives warm hand-offs from providers or health team members for patients with behavioral health needs who presented for a medical appointment.
• Conducts assessment and screening to assist in diagnosis and treatment and plan development.
• In consultation with the patient, their care team and related partners, develop a care plan including immediate, short term, and long-term goals reflecting patient's priorities and time frames to achieve desired outcomes.
• Demonstrate knowledge and understanding of the client's diagnosis, prognosis, care needs, as well as cost and barriers to goal achievement.
• Outreach to patients who miss appointments to check in and address any barriers. Follows up with at-risk patients keep them engaged and connected to resources.
• Assist in transition of care though patient outreach, communication with relevant service providers following discharge from other care settings to ensure a smooth transition to outpatient care, with the goal of decreasing readmissions.
• Communicate with patients and families in an effective, patient-centered manner; coordinate with other team members to provide exceptional patient service.
• Maintain positive working relationships and demonstrate exceptional customer service skills. Work cooperatively, address conflict and communicate effectively with all providers, team members, patients and their families
• Facilitate patient access to appropriate service and treatment providers as well as other care coordination team support
• Serve as a point of contact, advocate, and informational resource for patient, family, care team, payers, and community resources and facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed
• Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
• Supports patient self-management of disease and behavior modification interventions.
• Proactively outreaches to selected patients, perform home visits as necessary for assessment and engagement
• Participates in quality improvement activities, collecting and analyzing data

• LPN, Med. Asst. Cert., LCSW, LICSW, or LMHC
• Experience working in a healthcare setting as a member of a professional clinical team is required.
• Knowledge of community resources and supports, BH/SUD treatment as well as experience in referral for treatment, support, and services
• Experience in providing evidence-based brief interventions to individuals with BH/SUD conditions including Motivational Interviewing, Behavioral Activation, CBT, and Problem-Solving Tx.
• Ability to form rapid engagement and alliance-building with patients and their families.
• Ability to follow the logical management of a member's care throughout the continuum of care.
• Possesses a basic understanding of applying clinical criteria when determining medical necessity.
• Proven ability to work independently and adjust to multiple demands and shifting priorities, ambiguity, and rapid change with resiliency.
• Computer literacy is required with the ability to manage multiple open applications.
• Ability to work autonomously and with meeting goals for productivity
• Ability to complete work assignments accurately and in a timely manner
• Ability to communicate effectively, both orally and in writing
• Ability to handle difficult situations involving patients, physicians, or others in a professional manner

Interested candidates should provide a cover letter addressing the scope of the role, in addition to completing the application.

All new hires are required to show proof of COVID vaccination or request an exemption prior to starting work.

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