- Job date: Thu, 18 Feb 2021 04:59:47 GMT
- Expected salary: $32.48 – 37.77 per hour
- Job title: Health Home Care Coordinator (Counselor)
- Company: City of Seattle
- Location: Renton, WA
Human Services, a department of the City of Seattle, funds and operates programs and services that meet the basic needs of the most vulnerable people our community – families and individuals with low incomes, children, domestic violence and sexual assault victims, homeless people, seniors, and persons with disabilities. We invest in programs that help people gain independence and success.
The City of Seattle Human Services Department is seeking an experienced Home Health Care Coordinator (Counselor) to join the Aging & Disability Services Division. The successful candidate will join a team of enthusiastic, energetic, and dedicated colleagues who provide Care Transitions and Care Coordination for clients throughout King County. The Care Coordinator helps support individuals with complex medical conditions where they reside and will collaborate with medical providers in inpatient and clinic settings, and other key partners to maximize health care resources and positive health outcomes for clients.
The Care Coordinator will be a key member of the patient’s healthcare team, support clients as they develop their self-management skills, and assist clients with navigation of the healthcare and safety net systems. The Care Coordinator will facilitate clients towards self-care through coaching, education, coordination, and follow up.
Client population includes older individuals and adults with disabilities, living at home and/or living in government funded residential setting or skilled nursing facility, who have unstable health conditions and risk factors including multiple physical and/or mental health problems, long-term care needs, and/or drug/alcohol issues. Clients may include those who have difficulty sustaining basic living needs due to their physical, emotional, behavioral or cognitive status, and physical or emotional neglect or abuse.
The Health Care Coordinators directly interacts with Health Home service beneficiaries service beneficiaries and is responsible for the conversion of beneficiaries from outreach to engaged. Care Coordinator works with clients to develop a Health Action Plan that includes a client-driven long-term goal, coinciding short-term goals and specific action steps as well as required and clinically indicated screenings. The Care Coordinator is responsible for supporting comets and their families in coordinating the beneficiary’s healthcare services and increasing the client’s and family’s knowledge and skills to be able to self-manage healthcare needs.
The Care Coordinator provides six Health Home services to clients on caseload as appropriate and needed. These services include comprehensive care management, care coordination and health promotion, transitional care planning and follow-up services, individual and family education and collaboration, community and social support services referral coordination, and use of health information technology.
The Care Coordinator will communicate with authorizing entities and the patients’ s interdisciplinary team to ensure quality and continuity of care according to beneficiary’s goals. The Care Coordinator will provide services in the community where the beneficiary resides and services will be provided in-person when needed at the location of beneficiary’s request. (modified currently due to COVID-19 to monthly telephonic or virtual appointments) The role of the Care Coordinator involves direct coordination, advocacy, and education to assist the client in understanding the healthcare system and to access services for physical and behavioral health needs.
This position is located in Renton (600 SW 39th Street, Renton). This requisition may be used in the future to hire temporary, or out-of-class Care Coordinators for our case management program in either Renton or Seattle.
- Engaging clients to enroll in the Health Home program.
- Conducting community and facility-based client-centered outreach to engage eligible and interested beneficiaries in Health Home services and educate community partners about Health Home services.
- Managing caseload of 45-55 clients (FTE caseload) to assure quality and timely services are provided to each engaged client in Health Home services. Takes initiative with managing needs of caseload and maintaining day-to-day schedule and consults with supervisor and care team as needed.
- Identifying barriers to care and assisting clients to navigate these barriers and access the right care at the right time
- Using clinical skills to assess, manage, monitor, and empower patients. Supporting patient self-management by providing coaching and education to patients and families using the Care Transitions and Chronic Care Model principles.
- Performing monthly visits in-person visits that include assessments of the client’s health, medication management, environmental factors and/or other barriers that impact client’s ability to access appropriate health care services. *Visits are being conducted remotely during Covid-19 pandemic.
- Completion of a Health Action Plan with each client.
- Review and update Health Action Plan every four months.
- Intensive case monitoring and coordination to include monthly in-person visits with clients (at location of client’s preference, including home, inpatient setting, clinic, etc.)
- Developing and maintaining community partnerships, identifying patient advocacy issues, meeting Care Transitions patients prior to hospital discharge, attending a medical appointment with the patient when appropriate, and working effectively as a change agent to promote patient self-management.
- Responding to the changing needs of the patients, clinic, and work in partnership for joint accountability with other members of the patients’ healthcare delivery team.
- Working collaboratively with multi-disciplinary care teams, relevant community groups, and multicultural professionals promoting health outcomes, patient self-management, and positive community partnerships.
- Work with interpreters to provide services to persons who do not speak English.
- Timely document all client activities and contacts (referrals, additional contacts, and other in-home visits, etc.) and maintain confidential client record.
- Maintain work standards to ensure compliance with Quality Assurance and HIPAA expectations.
Education: Bachelor’s degree in Social Services, Psychology or a related field
Experience: Three years’ social services experience involving interviewing, counseling, or crisis intervention.
Or a combination of education and/or training and/or work experience which provides the ability to perform the work of the class.
Certification/License: Driver’s license for the ability to make on-site visits to clients and attend meetings and trainings. A “Full Driver Abstract Record” will need to be provided from the State of Washington Department of Licensing. (It will be required at the interview stage at the applicant’s expense).
- Extensive care management experience with elderly and/or adults with disabilities – which includes proven skills in Outreach, Coaching and Motivational Interviewing and behavior change strategies.
- Experience conducting comprehensive medical/psychosocial assessments.
- Understanding of substance use disorder, mental health and socio-economic issues that affect individual’s abilities to remain stable in the community.
- Experience working with clients who are high utilizers of health care systems to reduce inappropriate emergency room utilization and hospital readmissions.
- High degree of medical knowledge including experience developing and educating patients with self-care tools and procedures and experience with teach back method.
- Experience working in major social, health, and/or government agencies serving elderly and/or disabled populations.
- Experience using Care Transitions models to decrease preventable re-hospitalization.
- Experience using Trauma Informed Care and Harm Reduction strategies
- Experience working with elderly or disabled adults who have unstable health conditions and risk factors including multiple physical and/or mental health problems, long-term care needs, and/or drug/alcohol problems.
- Experience developing and implementing individualized service plans with proven ability to maintain confidential records.
- Proven ability to engage difficult to serve individuals.
- Strong understanding of race and social justice issues that lead to health inequities.
- Strong written, verbal, and interpersonal communication skills with the ability to tactfully and effectively communicate with staff, community-based organizational groups, and government agencies.
- Comfortable working in a fast-moving, collaborative, team-oriented environment.
- Ability to adjust to frequent changes in policies, procedures and priorities.
- Ability to travel to attend meetings, trainings, and conduct in-home visits with clients.
- Ability to work effectively within diverse workgroups and populations with proven ability to collaborate with community based and governmental agencies.
- Excellent time management skills
- Proactive client-centered and solution focused approach to problem solving.
- Demonstrated proficiency with technology related to electronic medical records and use of electronic mail and industry standard computer software including Microsoft Office (i.e. Word, Outlook, Excel, etc.).
- Bilingual with the ability to read, write and speak another language besides English (preferably Spanish, Russian/Ukraine, Bosnian, American Sign Language, Somali and/or Punjabi).
Your application will not be reviewed if these items are missing or incomplete.
Applications are reviewed after the posting closes. Qualified candidates must submit the following to be considered:
- Completed NEOGOV online application.
- Supplemental questionnaire responses.
- Cover letter describing how your skills and experience align with the stated job responsibilities and qualifications.
Offers of employment are contingent on verification of information provided by the applicant as part of the application process, including potential background check, pre-placement physical exam, and full driver’s abstract. For those using the equivalency for the education requirement, job offer is contingent upon waiver approval from the Health Care Authority.
Please note this job advertisement is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
For more information on the Human Services Department, please visit: .
The City of Seattle offers a comprehensive benefits package including vacation, holiday and sick leave as well as medical, dental, vision, life and long-term disability insurance for employees and their dependents.
More information about employee benefits is available on the City’s website at: