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Coordinate the delivery of integrated care services to members by collaborating with clinical staff, community systems, and other stakeholders to address comprehensive treatment needs.
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Conduct outreach and engagement efforts in community settings including homeless camps, shelters, emergency departments, jails, detox centers, and other identified locations, with emphasis on high-risk populations such as pregnant individuals, IV drug users, and justice-involved persons.
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Perform initial screenings, assessments, urgent engagements, diagnostic evaluations, and annual updates in both community and crisis settings.
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Assist members with diversion or stabilization, pre-enrollment services, and linkage to Medication-Assisted Treatment (MAT).
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Facilitate intake and enrollment in care by coordinating with internal staff and supporting members throughout the process.
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Facilitate care coordination with internal staff for members who are admitted and discharged for identified and allocated community systems and stakeholders.
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Provide transportation and accompaniment to medical, behavioral health, legal, and social services appointments as needed.
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Conduct integrated healthcare assessments and identify barriers to treatment or health access, making appropriate interventions or referrals.
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Support members in following through diagnostic tests, treatment recommendations, and medication adherence, offering education and navigation.
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Obtain and file relevant health records and provider notes in the electronic health record while ensuring documentation is complete and timely.
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Develop, implement, and revise integrated service plans and monitor progress on treatment goals and crisis plans.
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Provide consistent follow-up on referrals and maintain regular contact with treatment teams to track member progress and ensure continuity of care.
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Offer individualized education, advocacy, and support through home-based, office-based, and community-based services.
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Maintain accurate written records of outreach efforts, enrollment potential, and service delivery.
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Assure accurate billing is submitted for each interaction and/or activity supporting a member’s treatment goals.
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Perform crisis intervention, de-escalation, and reengagement outreach via various methods including phone, home, and jail visits.
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Attend required staff meetings, training, and participate in interdisciplinary case conferences.
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Support other departments in service engagement efforts and contribute to continuous program development.
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Coordination of 24/7 hour lines and support of after-hours responsibilities
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Perform additional duties in line with agency growth and evolving service needs