PURPOSE OF THE POSITION

The Community Referral Coordinator will work as part of an interdisciplinary team and will meet with members to help connect them with applicable community resources. This position is responsible for assessing, care planning, and connecting members to a variety of community-based services including but not limited to medical, substance use recovery-oriented services, mental health services, medication management, housing/food support, transportation, peer support, and other member needs that may arise.

ESSENTIAL JOB FUNCTIONS

• Working with the member, primary care provider, supervisor and other members of the health services team (EAP, Case Managers, Fitness, TPA, etc.) to identify and prioritize member's health care goals 
• Identifies, facilitates and secures access to needed medical and mental healthcare services and appointments, social service benefits and community resources for the client’s member population and dependents. This includes: assisting members with completing housing and social service applications, accessing transportation, obtaining needed medical and social information to move applications forward, connecting member to appropriate agency to address needed services.
• Performs liaison functions between City agencies, residents, and community organizations, to provide assistance and facilitate participation in public service programs.
• Documents all encounters and follow up plans in Epic. 
• Coordinates and attends meetings and collaborates with community partners to move the member toward stability.
• Works in collaboration with health services team members and care providers both in the facility and in the community including but not limited to: behavioral health services, disease care management specialist, social workers and community-based organizations to help the member maintain bidirectional communication and achieve optimal health outcomes.
• Assists members in scheduling appointments for clinical/medical and other community-based social services and assists with arranging transportation as needed to ensure access to services.
• Participates in case conferences to ensure that each member’s care team is aligned with a shared plan of care and up-to-date information on each member. Provide written status updates on a regular basis as requested and verify documentation of all such activities in member chart.
• Adheres to timeframes and quality standards regarding completion of member assessments, reassessments, care plans, and documentation (including case notes, updates, consents, etc.). 
• Maintain a directory of provider services including medical, behavioral health, social support and other services as needed to support referral and coordination activities. Identify valuable resources to share with the rest of the team to the benefit of all members. 
• Maintain positive and productive personal presentation with internal and external contacts, ensuring all engagements with staff/coworkers, members, and community partners are professional, courteous, and respectful. 
• Attend program meetings, community meetings, committees, and trainings as requested; maintain and promote a positive image of Premise Health and the client with the goal of fostering positive community relations to the benefit of the served members and agency mission at large.
• Is familiar with the Premise Health policies and procedures to assure quality assurance and quality improvement are properly implemented as needed.
• Complete an in-depth initial needs assessment; subsequently completing and overseeing a member centered plan to address at risk areas.
• Implementation of the plan addressing at risk areas with documented follow up and monitoring of the plan
• Provide advocacy and knowledge of available and appropriate services for members and their families/collaterals.
• Participate in case conferences with the member care team on an as needed basis (with a minimum on case conference every three months with the exception of the Highly Utilizers member)
• Being available for referral for crises intervention, having to remain with a member until the issue is resolved or addressed.
• Complete accurate and up to date documentation; conduct daily follow ups to address any issues, review the previous day’s activities, and to discuss any client issues and or/new insight regarding a member.
• All other duties as assigned.

BASIC QUALIFICATIONS

Education:

• High School diploma/GED

Experience:

• Prior experience accessing and navigating community resources preferred.

Knowledge and Skills:

• Be able to work in and create a positive attitude environment, manage caseload, complete task/duties and address conflicts as they arise. 
• Communicate effectively with supervisory personnel in a cooperative and supportive manner.
• Be able to tolerate the ambiguity during transition time and take on other assignment as needed.
• Excellent problem-solving skills and ability to build positive relationships 
• Excellent verbal and written communication skills in a customer service environment 
• Excellent time management, organization, research, analytical, negotiation and interpersonal skills