ABOUT INTEGRATED HEALTH HAWAII
Integrated Health Hawaii (IHH) was established in 2018 by the physician organization, Pacific Medical Administrative Group (PMAG), to help physicians care for their patients by providing supportive services. Initially founded to help children with special health care needs (CSHCN), IHH developed a pediatric care coordination program, Kapili Kokua, to improve access to health care services and community resources. IHH expanded its services to adults, developing a care coordination program to assist individuals with health problems. IHH has connected over 4000 patients to an array of services in the state, utilizing its community relationships, network of vetted mental health professionals, and engagement-focused care coordination approach.
CARE COORDINATOR JOB DESCRIPTION
The Care Coordinator (CC) is a core member of the collaborative care team, which includes the patient’s primary care physician (PCP) and other behavioral health/medical team members. The CC is responsible for supporting and coordinating the health care of patients on an assigned patient caseload.
DUTIES AND RESPONSIBILITIES
- Patient Review: Evaluate patients’ needs and develop personalized care plans by gathering comprehensive information about their medical history, current health status, and personal circumstances. Work closely with physicians and specialists to ensure a thorough understanding of the patient’s condition.
- Care Planning: Create and implement care plans tailored to patients’ unique needs, including their physical, emotional, and social aspects. Collaborate closely with healthcare providers, including physicians and specialists, to ensure the care plan is effectively followed and adjusted as necessary.
- Resource Navigation and Management: Identify and connect patients with necessary resources, such as medical services, community support, and financial assistance. Work with the care team to ensure patients have access to appropriate resources and services.
- Communication: Serve as a liaison between patients, families, and healthcare providers. Facilitate effective communication and information sharing with physicians, specialists, and other members of the care team to ensure all parties are well-informed and coordinated.
- Monitoring and Follow-Up: Track patients’ progress and make adjustments to care plans as needed. Coordinate and schedule follow-up appointments, tests, and treatments with physicians and specialists to maintain continuity of care.
- Advocacy: Advocate for patients’ needs and preferences within the healthcare system. Collaborate with physicians and specialists to help patients navigate complex medical and administrative processes, ensuring their voices are heard and their needs are met.
- Documentation: Maintain accurate and detailed records of patient interactions, care plans, and progress. Ensure documentation adheres to relevant regulations and standards and share pertinent information with the care team as needed.
- Education: Educate patients and their families about their conditions, treatment options, and self-care techniques. Provide clear guidance in collaboration with healthcare providers to support informed decision-making.
- Cultural Humility and Awareness: Practice cultural humility by recognizing and respecting patients’ diverse backgrounds, values, and beliefs. Incorporate cultural awareness into care planning and communication to provide respectful and personalized care, in partnership with the care team.
- Community Engagement: Demonstrate a strong interest in serving community members from various backgrounds. Engage with diverse populations to understand their unique needs and challenges, and work with the care team to address health disparities within the community.
- Additional Duties: Carry out other responsibilities as assigned by supervisors or healthcare organizations, which may include participating in quality improvement initiatives, attending training sessions, and contributing to organizational goals, while collaborating with physicians and specialists.
TRAINING, DEGREES, and CERTIFICATION REQUIREMENTS
- Bachelor’s degree in a relevant field including BSN, BSW, Public Health, Health Administration, and Psychology.
- High school diploma with a certificate in Community Health Work.
- Optional: Master’s in nursing, social work, public health, health administration, or psychology.
OTHER REQUIREMENTS
- Demonstrated ability to collaborate and communicate effectively in a team setting.
- Ability to maintain effective and professional relationships with patients and other members of the care team.
- Experience with screening for common mental health and/or substance abuse disorders.
- Working knowledge of differential diagnosis of common mental health and/or substance abuse disorders, when appropriate.
- Ability to effectively engage patients in a therapeutic relationship, when appropriate.
- Ability to work with patients by telephone as well as in person.
- Experience with assessment and treatment planning for common mental health and/or substance use disorders.
- Working knowledge of evidence-based psychosocial treatments and brief behavioral interventions for common mental health disorders, when appropriate (e.g., motivational interviewing, problem-solving treatment, behavioral activation).
- Basic knowledge of psychopharmacology for common mental health disorders that is within appropriate scope of practice for type of provider filling role.
- Experience with evidence-based counseling techniques.
CONTACT
To apply for this position, please email your cover letter and resume or CV in PDF format to Program Manager, Kaleen Terayama at kterayam@integratedhealthhawaii.com.
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