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Care Coordinator- Hub and Spoke

Company: Wisconsin Community Services
Location: Milwaukee
Posted on: November 22, 2021

Job Description:

Care Coordinator- Hub and SpokeJob Code: 2021-SPECIALI-026Location: Division of Specialized ServicesDepartment: Hub and SpokeFT/PT Status: Full TimeJob Responsibilities: CARE COORDINATOR- Hub and SpokePosition Summary: The Hub and Spoke Health Home is an innovative model serving people with significant substance use and co-occurring mental health needs. The Care Coordinator works in collaboration with the Peer Specialist and is responsible for working with the individual to develop the individualized comprehensive care plan, facilitate monthly team meetings, and update the care plan every 90 days. The Care Coordinator will ensure people are receiving comprehensive and quality care from the team, spokes, and community service providers. The Care Coordinator meets with each individual weekly and advocates with the person to meet their identified needs. Essential Functions: Committed and skilled at engaging people through a strength based, trauma informed, person centered, and culturally intelligent approach. This position has a strong focus on engaging people in care and services. Committed and passionate about serving people with substance use and co-occurring needs. Closely collaborate with Peer Specialists and the WCS Hub Team to serve people referred to the program. Closely collaborate with spokes to support connection to ongoing medical and treatment services. Weekly goal focused face to face contact with each person being served by the Care Coordinator. Responsible for developing the individualized Comprehensive Care Plan in the person's own words. A Comprehensive Care Plan is focused on the person's strengths, goals, and strategies to meet the identified needs. Comprehensive Care Plans are updated a minimum of every 90 days. Focused on providing comprehensive care to meet the person's needs. This includes treatment needs, medical/dental, housing, legal, financial, benefits, food, clothes, and social needs, etc. Facilitate monthly team meetings and Comprehensive Care Plan meetings (every 90 days) in collaboration with the person's care team. Coordinate care with providers of services and verify services are provided. Contact each member of the person's care team a minimum of weekly to review progress and areas of ongoing need. Work closely with the person to develop a team of informal supports (i.e. family members, friends, support groups, church, etc.) and formal supports (formal paid providers) based on the person's preference. Collaborate with the benefits specialist to review benefits and additional needs. Provide transportation and attend appointments with the person. Advocate with the person to meet identified needs. Provide introduction to new team members joining the team. Support crisis response and developing strategies to meet immediate needs. Develop a comprehensive crisis plan with the individual. Follow all WCS Hub policies and procedures. Embrace a comprehensive team approach to meet the individualized needs of people with complex substance use and life needs. Network with community providers and Spokes to develop collaborative relationships to meet the needs of the people being served by the program. Document all interactions, collateral contacts, and activities specific to the individual's care and treatment in the electronic medical record within 24 hours of the contact. Complete all WCS Hub and Spoke Health Home training and WCS specific training. Uphold and promote a positive, strength based, and supportive culture. Maintain confidentiality within all written and verbal communications. Adhere to WCS Policies and Procedures. Other duties as assigned. Other Duties and Responsibilities: Other job-related duties as may be necessary to carry out the responsibilities of the position.Job Qualifications: Minimum Qualifications: Minimum of a high school diploma or equivalent and experience serving people with substance use needs or a Bachelor's degree in Social Work, Psychology, Nursing, or Social Services from a school of social work or in a behavioral science. Knowledge and experience serving people with substance use need. Working knowledge of computer applications preferred (Windows and Microsoft Word). Ability to display cultural competence by responding respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, and other diversity factors in a manner that recognizes, affirms and values the worth of clients. Valid driver's license, automobile, and insurance sufficient to meet agency requirements. Meet all the employee requirements including references, criminal background check, drug screen, and driver's license check. Other Job Information (if applicable): Work Relationship and Scope: Reports directly to the Team Supervisor and works closely with the WCS Hub and Spoke Health Home team. Direct interaction with the people being served by the program, staff, project partners, substance use treatment providers, and Milwaukee County. Personal Attributes: Follow agency Code of Conduct and adhere to established policies and procedures of the agency and of all funding sources including Wisconsin DHS. Conduct self in an ethical manner. Maintain professional and respectful relationships with all WCS staff, adults, and families and all external funding sources and community partners involved with service provision. Show sensitivity toward cultural, ethnic, and disability needs. Embrace the role and utilization of peer specialists and people with lived experience. Knowledge, Skills, and Abilities: Experience serving people substance use and co-occurring needs. Knowledge of the Milwaukee County substance use system, Medication Assisted Treatment, and evidence-based practices. Must possess verbal and written communication skills, along with computer skills that include Microsoft Word, Excel, and database applications. Must have strong communication skills, be flexible, patient, and compassionate and maintain confidential information. Must have the ability to work independently with a minimal amount of supervision but must be a strong team player as well. Ability to multi-task, take initiative and apply knowledge to variety of circumstances. Working Conditions: Work is performed in an office and community environment. Work is performed in the community including going into homes, court, and other locations to serve adults enrolled in the WCS Hub and Spoke Health Home. Travel is required. Must be comfortable being around and/or interacting with adults who have significant substance use needs. Flexible work schedule is required to meet the needs of staff and the people being served. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. Physical Demands: May require sitting at a desk and/or computer for two or more hours at a time. Requires computer work. Travel in the community is a requirement.pm21PI154357540

Keywords: Wisconsin Community Services, Milwaukee , Care Coordinator- Hub and Spoke, Other , Milwaukee, Wisconsin

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