Job Description

The Charlotte Community Health Clinic (CCHC) is a non-profit agency whose vision is to provide a healthy community where all individuals regardless of ability to pay will have access to comprehensive coordinated quality healthcare. The clinic provides quality, accessible primary care, behavioral health, and dental services to pediatric and adult patients coming from a wide range of cultural and socioeconomic backgrounds, including patients experiencing homelessness. CCHC works in partnership with other community-based organizations to meet the needs of the medically underserved.

Job Summary:

The BH Care Coordinator is responsible for providing assistance to the CCHC care team

First, this position will support the care management team by working collaboratively to support patient care plans and needs. Serving as an advocate for patients, the BH Care Coordinator will be part of the care management team and work in tandem with care managers, healthcare providers and community-based organizations to improve outcomes for patients they serve. Second, this position will also support primary care behavioral health (PCBH) population health management, identifying at-risk patients and connecting or reconnecting them with behavioral health or their primary care provider.

Working within his/her scope of practice, this role coordinates between health care services, recognizing the holistic needs of the patient, inclusive of patient specific social and cultural dynamics. This position will support CCHC goals and objectives in meeting performance improvement targets, meeting expectations of standardizing the plan of care, and supporting team development.

Responsibilities:

Care Management (50% of role)

Engages with patients to identify and address barriers that impede health outcomes

Implements and supports Care Management interventions per the patient’s care plan or assessed community needs

Processes referrals from members of the multidisciplinary team (social work, behavioral health, community resource coordinators, pharmacy, pharmacy technician, care managers) appropriately, accurately, and timely according to established workflows

Schedules home visits and/or practice encounters with patients via phone or correspondence based on referrals

Documents all interactions with patients/others appropriately in the care management software

Schedules/verifies appropriate medical appointments for patients as needed

Coordinates referrals to outside agencies as directed by interdisciplinary team in a timely fashion.

Provides education to patients/family within scope of practice

Serves as a liaison among the patient/family, community services, primary providers, specialists, and other care team members to coordinate services

Maintains appropriate documentation in the Care Management documentation platform, in accordance with organizational policies and procedures

Participates in Quality Improvement initiatives to improve efficiency and effectiveness of patient health outcomes

Adheres to CCHC privacy and security policies

Abides by Health Center guidelines, policies and procedures, and HIPAA regulations

Attends departmental and corporate meetings, local and regional training, or other events as required

Willingly performs other duties as assigned

Provides educational information to care team, patients, family and caregivers, about community-based organizations (existing and new) within service area

Works under direct supervision of the Chief Compliance & Nursing Officer (CCNO) with some additional daily oversight from PCBH Lead.

PCBH Population Health Management (50% of role)

Perform proactive population health management for the population with or at risk of developing behavioral health conditions

Review Better Outcomes Now registry for patients in need of care management outreach for re-connection to behavioral health and/or PCP (Primary Care Physician). Review for clinical appropriateness with assigned BHC & assist in the scheduling of that follow up

Review PHQ9s from satellite sites without in-person BHC for supported or independent follow up patient to connect them with behavioral health

Provide care coordination focused on the population of patients with behavioral health needs

Manage requests from care team for patient outreach after BH no-show or in other high-risk care contexts

Assist with referrals from BHCs for patients that require more intensive or specialty behavioral or substance abuse treatment

Qualifications:

High School graduate or GED; completion of certificate program in healthcare area of focus. Current and active certification or licensure from an accredited school or program

Minimum of (3) three years of experience in an ambulatory/care management or acute care setting, home health, or public health

Evidence of essential leadership, education, counseling skills, and strong interpersonal skills; ability to work with colleagues across sites.

Proficiency in communication technologies (email, cell phone, etc.)

Highly organized with ability to keep accurate notes and records

Experience with health IT systems and reports is desirable

Local knowledge about and connections to community health care and social welfare resources is desirable

Bilingual preferred but not required

BLS/CPR (or earned within 90 days of hire)

Ability to travel to other clinical sites when needed

Special Skill Requirements:

Core values consistent with a patient- and family-centered approach to care

Demonstrates professional, appropriate, effective, and tactful communication skills, including written, verbal, and nonverbal

Demonstrates a positive attitude and respectful, professional customer service

Acknowledges patient’s rights on confidentiality issues, maintains patient confidentiality at all times, and follows HIPAA guidelines and regulations

Proactively acts as patient advocate, responding with empathy and respect to resolve patient and family concerns, and recognizes opportunities for improvement to meeting patient concerns

Proactively continues to educate self on providing quality care and improving professional skills

The Mission of Charlotte Community Health Clinic is to provide the highest quality, patient centered, health care services for low-income and other underserved individuals.

Our Vision is a healthy community where all individuals, regardless of ability to pay, will have access to comprehensive, coordinated quality health care.

We screen potential employees to first ensure alignment with our core requirements followed by the requisite position skills set. In doing so, we need staff committed to this mission who will do their best to live and work the characteristics of our core values as we strive to care for ever increasing members of the communities we serve.

Company Description

Charlotte Community Health Clinic offers high-quality medical, dental, and behavioral health services for children and adults. We work towards a healthy community where all individuals, regardless of ability to pay, have access to comprehensive health care.

Benefits

• Health Insurance
• Dental Insurance
• Retirement Plan
• Paid Time Off (PTO)

CCHC Core Requirements

• 
  Patient Centered Customer Service – Whether directly or indirectly, we work to support the delivery of an excellent patient experience to everyone served by the organization.
• Caring and Compassion – We provide empathic comfort to those in distress and share kindness in all interpersonal interactions.
• Respectful Communication – We communicate openly, honestly and without judgment while honoring each individual’s uniqueness and assuming the best of those with whom we interact.
• Teamwork – We are members of a diverse interdisciplinary team working together to meet a common goal.
• Accountability – We accept our individual and team responsibilities, and we meet our commitments. We take responsibility for our performance and actions.
• Customer Safety – We recognize and correct potential hazards to protect our customers and ourselves.