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Health Home Care Coordinator (BA Level) 

About the Organization KMHS is Kitsap's nonprofit, designated community mental health provider for adults with acute and/or chronic serious mental illnesses, and children with serious emotional disturbances and their families. During 2016, KMHS provided services to more than 6,800 children and adults.

On WA's beautiful Kitsap Peninsula, offers easy access to both the pristine wilderness of the Olympic Peninsula and the big-city lights and culture of Seattle. We offer competitive salary, benefits & a positive work environment.

Inpatient, residential, and outpatient treatment services offer evidence-based treatment, using trauma informed care to help people reach their recovery goals. We offer whole person care through mental health and substance use treatment and care management, close care coordination with on-campus and community-based primary care providers, and with partner PCHS, now offer dental care to KMHS clients and the community. Many community partners assure people receive behavioral health care in the right place, in the right way, at the right time. Together we are weaving a web that connects emergency room and hospitals, substance abuse treatment, and primary care providers; creates partnerships for early intervention at home and school, supports multiple law enforcement, jail, and justice endeavors, and works to ensure housing, food, and other social supports together with social service agencies and community collaborations.

The Kitsap Mental Health Services community fosters a culture of hope and empowerment through a safe, welcoming environment, compassionate relationships, and a commitment to respecting life experiences.

KMHS is a tobacco/smoke-free and scent-free facility  
Category Social Services  
Open Date 3/5/2018  
Full-Time/Part-Time Full-Time  
Shift Days  
Location Kitsap Mental Health Services (Main Campus)  

The Health Home Care Coordinator functions as a core member of a collaborative care team that involves the patient's primary care provider, consulting psychiatrist and other primary care, nursing or specialty consultants, and an extended network of community healthcare and social service providers as well as Medicaid plans and programs. Health Home Care Coordinators assess patient needs, provide support, education and referrals, track medical and behavioral health outcomes and facilitate patient access to additional services including chemical dependency treatment, social services, long term supports and services, and other specialty medical and mental health care. The care coordinator is responsible for creating a Health Action Plan with individuals to address chronic medical, social, and behavioral conditions.

Essential Duties and Responsibilities

  • Provide community-based outreach , comprehensive care coordination, and health assessments. Support and closely coordinate medical, behavioral health care, and Long Term Supports and Services (LTSS) with the client's primary care provider and other treating providers.
  • Meet in person in members' homes and community settings and over the phone to to develop and track progress on a Health Action Plan (HAP). Evaluate client's support networks and systems, assisting them in navigating health delivery systems in medical and behavioral health care, community resources, and appropriate levels of care in the healthcare system as needed.
  • Screen, assess and provide patient education about health conditions,. Complete required periodic health and behavioral screenings, including mental, physical and chemical dependency validated screens such as the Patient Activation or Caregiver Activation Measure (PAM/CAM), PHQ9, KATZ ADL, etc as scheduled, employing evidence-based practices in screening and intervention.
  • Use decision support tools and registries to coordinate services and care across different settings and types of providers, identifying opportunities to streamline or otherwise improve services and eliminate duplication.
  • Monitor clients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications. Support medication management prescribed by PCPs, focusing on treatment adherence, attention to side effects, and effectiveness of treatment.
  • Provide brief intervention using evidence-based techniques such as behavioral activation, motivational interviewing, or other relevant skills. Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments as clinically indicated.
  • Participate in regularly scheduled (usually weekly) caseload consultation with the care coordination team. Work in a cooperative and collaborative manner as a team member. Assist in building positive working relationships with staff of all agency departments.
  • Facilitate efficient and timely care transitions by working with facilities and community based providers in extended networks to assure that clients transition smoothly among care settings.
  • Document client progress and treatment recommendations in the appropriate EHR so that this information can be easily shared with healthcare providers in the extended community network. Document in person and telephone encounters and identify and reengage patients who may be lost to follow-up.
  • Successfully navigate remote access and multiple software and web-based platforms relevant to patient health records and program operations technology including PRISM, Cisco AnyConnect, Insignia Health, Clinical Care Advance, CareManager, PsychConsult, WebEx, GoToMeeting, Sharepoint, ProFiler, etc.
  • Facilitate treatment plan changes for members who are not improving in consultation with the primary care health home. These may include changes in medications, psychosocial treatments or appropriate referrals for additional services. Complete relapse prevention plans with clients who are in remission.
  • Facilitate referrals for indicated social and specialty services (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment, DSHS interface).
  • Complete core training curriculum and participate in regular training and technical assistance activities for health home care coordinators. Complete all required KMHS and Health Care Authority trainings.
  • Maintain a safe and secure working environment
  • Performs other duties as required to accomplish the objectives of the position.

Position Requirements

Knowledge and Skills
This position requires knowledge of integrated whole person healthcare, chronic care management, common behavioral health concerns and differential diagnoses of common mental health and substance use disorders. Requires a working knowledge of evidence-based psychosocial treatments for common mental disorders and familiarity with brief, structured intervention techniques (e.g., Motivational Interviewing, Behavioral Activation).  Requires basic knowledge of typical symptomology, treatment, and pharmacology for common medical and mental disorders.  Requires a working knowledge of the RSN mental health and Long Term Supports and Services (LTSS) system structure and regulations.  Requires a working knowledge of personal computers including common office productivity software, internet, and computer-aided programs supporting client records, assessment/diagnosis, and treatment.  Requires strong communication, critical thinking, and organizational skills and ability to work independently.

Requires the ability to carry out the functions of and objectives for the position.  Requires the ability maintain effective, professional relationships with clients and other members of the care team.  Requires the ability to effectively engage clients in a therapeutic relationship in person and by telephone.  Requires the ability to relay professional terminology in common formats that enhance client understanding.  May require the ability to facilitate communications with clients who speak languages other than English.  Requires the ability to work comfortably with the pace of primary care.
Physical Abilities
Requires the physical and ambulatory ability to function effectively in inpatient and office environments, engaged in work of a largely sedentary nature.  Requires hand-eye-arm coordination ability to use a personal computer keyboard to access and record information.  Requires forward flexing and reaching ability to retrieve work materials and files.  Requires visual ability to recognize words, numbers, and non-verbal actions of people.  Requires auditory ability to project voice and carry out conversations with individuals and groups in person and over the phone.

Education and Experience

Bachelor's degree required. Psychology, social services, or a related field preferred; minimum of one-year experience working with clients with mental illness required.  Prefer experience in co-occurring disorders treatment, individual and group therapy, vocational services, or substance abuse treatment.   Possess and maintain valid driver’s license with an acceptable motor vehicle report and reliable, insured transportation. Requires experience with screening and assessment for common mental/ substance use disorders and experience with evidence-based interventions. Requires experience working with safety net providers and knowledge of community resources, and experience working with underserved, transient populations.  

Licenses and Certificates

  • Requires valid WA State Driver’s License and reliable, insured transportation.   
  • Requires ability to acquire Agency Affiliated Counselor registration
Salary DOE  
EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national origin, creed, marital status, age, Vietnam era or disabled veteran status, or the presence of any sensory, mental, or physical disability.

This position is currently not accepting applications.

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