Specialist, Care Coordination - Hybrid

Homage Senior Services, formerly Senior Services of Snohomish County is the largest and most comprehensive nonprofit service provider for older adults, people with disabilities, and their families in Snohomish County. Our guiding principles of independence, dignity, and quality of life are realized through our interconnected core service areas: nutrition, transportation, home repair, and social services. We are committed to building an inclusive workplace and offer you the opportunity to work to your fullest potential while making a difference in the community.

The Care Coordinator facilitates interdisciplinary collaboration across the care continuum. The primary role of the Care Coordinator is to empower the client/caregiver to assert a more active role during care transitions and to develop lasting self-management skills. The Care Coordinator will support individual clients with complex needs for several months. Supportive interventions may include a facility visit, home visits, as well as follow-up phone calls.

Essential Duties & Responsibilities

Developed from an evidence-based care transitions model, the Care Coordinator:

• Provides care transition intervention activities to eligible clients in the following domains: medication self-management, post-hospitalization physician follow-up, and knowledge of health risk factors.
• Encourages conversations about advance directives with clients and caregivers.
• Prepares and submits timely and accurate data reports on transitional care interventions.
• Educates health care providers and clients/caregivers regarding the important features of the care transitions model for the enhancement of care quality and smooth transitions.
• Works with the Health and Wellness team to develop trainings, tools and resources for implementation of interventions.
• Participates in trainings and seminars.
• Visits referred patients at home or prior to discharge/transfer to establish relationship, identify needs. Provides educational support as necessary.
• Provides visit to patients home as soon as possible following discharge from facility.
• Communicates with fire district personnel, hospital discharge planners, physicians, and ancillary providers as required to improve continuity of care.
• Follows up with client via telephone not less than three times following discharge to encourage self-management skills, confirm compliance with treatment plan and continue educational support.
• Serves as the bridge between the professional staff in a care setting (e.g. hospital) and the client and/or family. Also, collaborates with Aging and Disability Resource Network (ADRN) Specialists for continued care management support as applicable.
• Maintains accurate, timely documentation and databases on Care Coordination population.
• Collects and analyzes data on clinical indicators to identify opportunities for improvement.
• Develops, prepares and presents related records and reports. Participates in measuring clinical outcomes, data procurement and analysis activities.
• Regular and routine attendance
• Other duties as assigned

Minimum Qualifications

• Bachelors degree in a relevant field
• One year of experience in health care or social services setting.
• Ability to work independently with appropriate coordination among staff, clients, and community partners.
• Ability to apply and demonstrate Trauma-Informed Care practices to staff, clients, and community partners.
• Highly organized, able to work in a fast-paced environment and demonstrate prioritization skills/effective time management.
• Ability to shift from the clinical aspects of performing tasks, to empowering clients towards self-management.
• Demonstrated critical thinking skills.
• Effective written and verbal communication skills.
• General knowledge of health care delivery system in all settings.
• Broad knowledge of community resources.
• Ability to work with clients in environments with strong odors, pets or cigarette smoke.
• Effective working knowledge of Microsoft Office suite (Outlook, Teams, Excel, Word, PowerPoint); comfortable navigating in Microsoft Windows environment and using internet browsers.
• Valid WA State driver's license and current automobile insurance.

Preferred Qualifications

• Masters in Social Work (MSW)
• Experience working with clients in a teaching setting
• Experience working with elder and disabled populations
• Experience with diverse communities
• Fluency in other languages in addition to English

SUMMARY OF BENEFITS

Employees working 25 hours or more are eligible to enroll in medical, dental, vision, basic life, and critical illness insurance, with an increased cost share for employees scheduled for 25-29 hours/week. Employees working 20 hours or more per week receive 11 designated paid holidays plus 2 "floating holidays", as well as paid vacation and sick time. Employees age 21 and older are able to enroll in our 401K plan upon hire and, after one year and at least 1000 hours worked, will be eligible for our matching program.

New hires are budgeted to start in the $25-27/hour range, depending upon experience.