The Concerto Care Coordinator is responsible for providing care coordination services by working collaboratively with a team of individuals involved in the care team as they provide medical, behavioral, psycho/social care, health and wellness classes, and other related services and supports to Concerto members. Care Coordinators serve as an active advocate for the members’ rights. Plays a key role in the interdisciplinary care team and is a resource to the member, their families, and support systems.
Essential Duties and Responsibilities:
- Support an on-going person-centered planning process
- Assist the member to take a lead role in the process and provide information to the member and Integrated Care Team (ICT)
- Assess clinical risk and needs by conducting an assessment process that may include an Health Risk Assessment
- Facilitate timely access to primary care, specialty care, BH, SUD, and I/DD services, medications, and other health services needed by the enrollee, including referrals to address any physical or cognitive barriers
- Facilitate meetings of the Integrated Care Team (ICT), as needed or as requested by the enrollee
- Facilitate communication among the enrollee’s providers through the use of various methods of communication which may include electronic health records, secure e-mail, fax, telephone, and written correspondence
- Facilitate direct communication between the provider and the enrollee
- Facilitate enrollee and family education
- Facilitate the enrollee’s evaluation of the process, progress and outcomes
- Identify short term goals, long term goals, barriers to care and facilitate problem resolution
- Advocate with or on behalf of the enrollee as needed, to ensure successful implementation of the Individualized Care Plan
- Support transitions in care when the enrollee moves between care settings
- Engage in other activities or services needed to assist the enrollee in optimizing his or her health status, including assisting with self- management skills or techniques; health education; referrals to support groups, services, and advocacy agencies, as appropriate; and other modalities to improve health status.
- May be responsible for inpatient concurrent review.