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Coordinates the delivery of integrated care services to members, in collaboration with clinical and other staff to address the members needs.
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Performs integrated healthcare assessment and annual assessment updates.
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Assists in development, implementation and revision of integrated service plans; assures that services provided are specified in the integrated service plan and monitors progress toward treatment goals, crisis plans and coordinating of adult recovery teams.
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Monitors level and intensity of services contained in the members individual integrated service plans.
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Assist and support members to follow through on prescribed medical interventions and diagnostic testing.
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Inform and educate members regarding the meaning and implications of test results and prescribed interventions, as per clinic protocol.
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Assesses and addresses barriers to health.
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Obtain records, notes, reports, and consultations from primary, specialty and other providers and ensure that the information is appropriately filed in the electronic health record.
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Consults and cooperates with community systems to facilitate linkage, referral, crisis management, advocacy, and follow up with the focus on attaining treatment goals.
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Provides health literacy and health education groups.
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Offers guidance and education related to members individual needs.
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Provides community and home-based services to members.
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Connects members to resources within CODAC and the community to address identified health concerns.
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Review details and expectations about the referral with members.
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Provides member advocacy and attends medical appointments, as needed.
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Assists with coordination of scheduling of appointments for members.
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Attends all staff meetings and all other required meetings.
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Maintains member records in accordance with agency and funding source requirements.
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Participates in provision of Desk Duty services or Counselor of the Day to provide urgent and emergent services to members on a walk-in basis.
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Monitors progress and provides monthly updates to members involved with other agencies including Department of Developmental Disabilities, Department of Child Safety and Pima County and City of Tucson Diversion Courts.
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Maintains regular contact with treatment staff to inform and be informed of members progress and makes recommendations for continuing care.
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Transports members as needed and/or directed by supervisor.
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Performs other related duties in accordance with agency growth and changes.
