The Bridge’s mission is to change lives, by offering help, hope, and opportunity to the most vulnerable in our community. We offer a comprehensive range of evidence-based rehabilitative services, including mental health and substance abuse treatment, housing, vocational training and job placement, healthcare, education, and creative arts therapies.
Under the direction of the Clinical Supervisor, the Care Coordinator works with members and the member’s network of providers to help minimize barriers to care and help members achieve improved health outcomes. Using interventions such as care coordination, motivational interviewing, and health promotion, care managers help members, over time, develop the skills needed to manage their health and psychosocial needs with greater independence. Care Managers will have the opportunity to work as part of an outcome-driven integrated team aimed at improving the delivery of care to individuals living with chronic illness and behavioral health issues.
Essential Position Functions:
- Work with the population served by the Health Homes Program, which includes adults living with a serious mental illness, adults with chronic medical conditions, and/or individuals with a history of alcoholism and/or substance use disorders.
- Conduct initial assessments and reassessments of members’ needs, including medical, mental health, substance use, financial, housing, and support needs; develop person-centered care plans with documented input and approval from other providers and the member in adherence with Health Home standards.
- Work with member’s medical and behavioral health staff to develop, implement, and coordinate the care plan for clients with chronic illnesses, such as diabetes, asthma, congestive heart failure, hypertension, behavioral health conditions, and HIV, among other illnesses, based on the Health Home chronic disease care coordination model standards.
- Coordinate member services with all service providers through regular case conferencing in accordance with Health Home guidelines
- Conduct field visits to individuals in their homes or locations of their choice to provide services.
- Must be comfortable doing fieldwork in different settings like, but not limited to, shelters, SROs, substance abuse programs, mental health facilities, and hospitals; responding to questions and concerns and contacting other care providers and community resources to ensure that individuals are receiving needed care.
- Documentation of contacts and attempted contacts and all other documentation within the required time frames.
- Attend staff meetings, supervision, conferences, and training, as required; adhere to all approved Bridge personnel Health Home policies and procedures.
- Any other duties as may be assigned.
