COE Care and Outreach Coord - PPMC

Responsibilities:

• CARE COORDINATOR: Care Coordinator will meet with patient at least monthly to assess compliance, address patient needs and gain insight into unmet needs Coordinate information and patient needs (social service, health and medication) with appropriate interdisciplinary provider: PCP, social work, MAT provider, D&A provider, etc. Serve as an essential link between patients and all other care providers Care Coordinator is responsible for interacting with patient service representatives to expedite scheduling for follow-up and acute care appointments within UPHS Facilitate appointments for consults and support services within established service standards, including behavioral health clinicians, social workers, physician, community agencies, etc. Coordinate multidisciplinary team meetings; develop concise patient progress summaries for use by the care team, and document recommendations made utilizing standardized care protocols in accordance with state/nationally recognized care guidelines. Monitors and evaluates the delivery of care through documentation and tracking of needs addressed, track outcomes and support strategic planning through COE data collection in accordance with all State requirements. Assist in the development of patient education programs and tools. Follow patients throughout the care continuum, including inpatient admissions, discharges from all levels of care, and collaborate with inpatient care management resources. OUTREACH COORDINATOR Recognizes and capitalizes on opportunities in the community to explain the role of the COE/Care Coordinators and promote its use. Identifies barriers encountered both within the COE as well with community partners in regard to successful outcomes for clients. Respond to public and community inquiries on matters related to the COE Identify key stakeholders and work to connect with them to further expand the reach of the COE Build and nurture relationships in and outside of the Penn community. Attend community events relevant to the COE and be a representative of Penn Presbyterian’s Addiction and Behavioral Health Service lines Point person for the other care coordinators and helps monitor and oversee how the COE is executing on intended tasks.

Credentials:

Education or Equivalent Experience:

• H.S. Diploma/GED (Required)
• Education Specialization:
• Associate of Arts or Science
• Prior experience in behavioral health preferred. Knowledge of behavioral health resources in Philadelphia preferred Education Specialization: An Associate’s Degree in Behavioral Health, Nursing or related field of study required