Description

The person occupying this position acts as care coordinator who, as part of a care team, coordinates with medical professionals, clients, families, and the THL Program Director to provide services that promote overall wellness and linkage to primary care.

Requirements

1. To adhere to the current guidelines set forth by TN Care for Tennessee Health Link following the six services areas.
2. Self-management of care: Encourage and educate clients with steps toward self-management and care of their overall health-both mentally and physically. Link and refer. (Example: Teach client how to use bus for transportation. If client is unable to read-find resources to assist with reading skills.)
3. Comprehensive care management: Initiate, complete, update, and monitor the progress of a comprehensive person-centered care plan as needed. The initial plan is to be completed within 30 days of enrollment with reviews completed every six (6) months afterward or when a change in client status such as hospitalization. The plan must be signed by the care coordinator, member/guardian, and a licensed clinician. DLA is to be completed within 30 days of each Care Plan.
4. Care coordination: Participate in member’s physical health treatment plan, support scheduling and reduce barriers to adherence for medical and behavioral health appointments, facilitate and participate in regular interdisciplinary care team meetings, follow up with PCP, proactive outreach with PCP, and follow up with other behavioral health providers, pharmacy or clinical staff.
5. Health promotion: Educate the member and his/her family on topics that promote health-both mental health and physical health.
6. Transitional care: Provide additional high touch support in crisis situations, participate in development 
of discharge plan for each hospitalization, develop a systemic protocol to assure timely access to follow up care post discharge, establish relationships, and communicate and provide education 
7. Member and family support: Provide high-touch in-person support, provider caregiver counseling or training, identify resources to assist individuals and family supporters, and check-ins with member
8. Referral to social supports: Identify and facilitate access to community supports, collaborate client needs to community partners, and provide information and assistance in accessing services. Link and refer to social needs. 
9. Follow the AHS policy for attendance, including coming to work on time to prevent hardship on workflow. In case of absenteeism and tardiness, notify supervisor in acceptable length of time as outlined in AHS policy.
10. Documentation: To complete documentation within the require timeframe set forth by AHS which is within 48 hours of service delivery. The record will accurately reflect the client and the care plan following the six areas for THL. Documentation is professional and uphold the values and mission of AHS. Misrepresentation of information is not acceptable. Documentation must reflect and be coded with the actual time spent and service delivered.
11. Productivity: THL has billable services as outlined by TN Care. THL Manual describes the categories. A caseload is maintained to fulfill the obligation designed from TN Care for clients to be healthy-both with mental health and physical health. Different specialty areas of THL can have altered requirements. A THL Care Coordinator is expected to have an average of at least 8 unique clients and 10 services per day.
12. To attend required meetings and in-services. Annual trainings mandated for compliance need to be completed on time.
13. To maintain effective relationships with the professional clinical staff, administration and the clients of AHS. To promote a positive and professional encounter with outside entities.