General Responsibilities:

• Assess and re-evaluate patient needs utilizing information from EHR and additional tools as appropriate to determine patient needs and preferences and communicate those to all treatment participants
• Create an Integrated Care Plan in conjunction with the patient and/or caregiver
• Ensure the patient understands the Care Plan and is equipped to follow it
• Identify and address all barriers that might impede the ability of the patient to care for themselves
• Assemble appropriate team of professionals to assist in meeting patient needs, organize patient care activities and share information among all participants
• Assist the patient/caretaker in navigating the health system while addressing any insurance coverage issues
• Update assessment and care plan at least every 90 days
• Utilize the Integrated Care Plan to drive all activities and services
• Provide information and feedback in daily Huddles regarding needs, plans/interventions/results
• Research ways to meet needs and put action steps in place, monitor for progress
• Advocate on behalf of the patient
• Follow up regularly with patient to ensure needs are being met and identify any changes to patient circumstances, any compliance concerns
• Consult with treatment team when noncompliance is found
• Provide training on disease management and healthy living skills
• Provides initial Diabetes Care Introduction
• Provide support and education for patient and their support system
• Facilitate securing/providing medical records when patient is in the hospital, ED, etc.
• Track and support patients when they obtain services outside the practice.
• Follow-up with patients within a few days of an emergency room visit or hospital discharge.
• Communicate test results and care plans to patients/families.
• Collaborate and consult with staff members and outside sources in the delivery and arrangement of services
• Demonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situation
• Effectively demonstrates the application of adult specific competencies

Qualifications:
Bachelor’s degree in a behavioral health or social services related discipline preferred. HSD or GED with 2 years of experience working with individulas with psychiatric, substance use, and/or developmental disabilities required in lieu of degree. Must meet all driving requirements.