Website Alluvion Health
Creating and Inspiring Healthier Lives
Creating and Inspiring Healthier Lives.
Position Title: Re-Entry Care Coordinator
Department: Inmate Medical Services – CCDC
Supervisor: Jail Diversion Program Manager
Supervisory Responsibilities: None
FLSA Status: Non-Exempt
The Re-Entry Care Coordinator works as a core member of the Collaborative Care Team that involves the patient’s primary care provider, nurse, medical assistants, and/or mental health providers in the health center and outside agencies or providers as appropriate. This position is primarily located at the Alluvion Health Satellite Clinic that is located at the Cascade County Detention Center (CCDC). The Re-Entry Care Coordinator is responsible for coordinating and supporting primary medical, dental and/or mental health care within the inmate medical clinic, and with community resources to help streamline successfully re-entry of individuals. This will help ensure those receiving care as part of inmate medical services, have the ability to maintain necessary services upon their release. The Re-Entry Care Coordinator provides excellent customer service to patients and providers, while ensuring access to care, assessment for additional services if qualified, and coordination of non- traditional healthcare services to ensure whole patient care is achieved. The Re-Entry Care Coordinator is or will be certified as a Certified Application Counselor to provide outreach and enrollment services for Marketplace insurance and/or Medicaid enrollment. The Re-Entry Care Coordinator is an active participant in clinical team huddles and care planning activities. In addition, the Re-Entry Care Coordinator participates in education and outreach events as needed in the community.
All employees will exhibit the following behavioral traits:
Integrity and Trust
Individual is widely trusted and can present information and discuss situations in an appropriate and helpful manner, keeps confidences, admits mistakes, doesn’t misrepresent him/herself for personal gain. Is respectful in action and communication with clients, patients and staff.
Adheres to the organization’s mission during times of ease or challenge, is dedicated to the expectations and requirements of the mission and vision, acts in line with the values identified by Alluvion Health.
Understands and supports the team approach and integrated model of Alluvion Health. Is seen as a team player, cooperative and supportive of his/her coworkers, practices what he/she preaches. Can be candid with peers and fosters open dialogue. Creates a feeling of belonging on the team and holds self and team accountable to those behaviors.
Essential Job Responsibilities:
1. Support and closely coordinate primary and/or mental health care with the patient’s primary care provider, mental health providers, specialists, or other community resources;
2. Screen and gather information from patients;
3. Use evidence-based tools to track patients (in person and by telephone) for changes in clinical symptoms and gather information about treatment side effects or complications; coordinates with other members of the care team as needed;
4. Facilitate in-clinic referrals for other Alluvion Health services such as outreach and enrollment, dental, prescription assistance, etc.;
5. Participate in regularly scheduled caseload consultation with the care team. Facilitate communication regarding treatment recommendations to the patient’s PCP;
6. Support patient engagement and follow-up in care;
7. Evaluate patient care plans with care team;
8. Document patient encounters, patient progress, treatment, and follow-up care in the electronic medical record system within the scope of practice;
9. Facilitates referrals for clinically indicated services outside the community health center (mental health specialty care, substance abuse treatment, housing assistance, etc.);
10. Attend and participate in meetings and Quality Improvement activities as required;
11. Serve as a member of committees as requested;
12. Participate in peer review as part of Quality Improvement activities and in compliance with health center policies;
13. Maintains confidentiality according to HIPAA;
14. Works as a team player with staff and other community organizations to ensure quality services and program requirements are met to carry out the goals and objectives of the health center program;
15. Performs duties efficiently and effectively;
16. Follows Alluvion Health policies and procedures;
17. Establishes and maintains productive working relationships with fellow employees, supervisors, and the public;
18. Performs other duties or projects as required to accomplish the objectives of the position;
19. Ensures compliance with HIPAA/HITECH;
20. Maintains compliance standards in accordance with the HRSA compliance policies, HIPAA, HITECH, FTCA and the Code-of-Conduct and reports concerns timely and appropriately;
21. Performs a variety of other duties as assigned; which may include but are not limited to: directing or participating in special projects and events, conducting research, representing Alluvion Health at meetings and conferences, and attending continuing education and training events.
Knowledge and understanding of:
• Basic computer data entry;
• General office practices;
• Community resources;
• Cultural sensitivity;
• HIPAA Privacy and Security Rules;
• Safety policies and procedures.
• Time management and organization;
• Strong communication;
• Microsoft Excel, Word, Outlook, Windows, Internet, electronic medical record systems;
• Customer service;
• Written and verbal communication.
• Operate a variety of software applications;
• Multi-task on diverse projects
• Research detailed information and compile data
• Collaborate effectively in a team setting;
• Maintain effective and professional relationships with patients and other members of the care team;
• Effectively engage patients in a therapeutic relationship, when appropriate;
• Screen for common mental health and/or substance use disorders;
• Assess patients and create treatment plans for common mental health and/or substance abuse disorders;
• Respond appropriately to an emergency or crisis situation;
• Adapt to changes in the work environment;
• Manage competing demands, changes in approach or method to best fit the situation;
• Deal with frequent change, delays and or unexpected events;
• Adhere to a high degree of confidentiality and sensitivity towards the families involved;
• Maintain confidentiality and compliance with HIPAA privacy and security rules;
• Work with patients with diverse social economic and cultural backgrounds in an empathic, non-judgmental, respectful and professional manner;
• Work with people from all walks of life, such as individuals with various social and emotional histories, high risk, unemployed, and homeless, abused and people with mental health conditions;
• Work independently with little direction but also with a team;
• Read and comprehend materials;
• Analyze and compile information;
• Pass a criminal background check;
• Observe required work hours;
• Communicate effectively orally and in writing;
• Demonstrate punctuality;
• Meet established timelines and/or deadlines;
• Observe established lines of authority;
• Identify problems that adversely affect the organization and its functions;
• Offer suggestions for improvements.
Employees located at this site, must:
• Follow all security regulations of CCDC. Alluvion Health personnel are subject to removal from facility at any time for security reasons as determined by the
Undersheriff, Detention Facility Administrator or his/her designee.
• Support intake screening, health assessments, transfer screenings, sick-call services, segregation rounding, discharge services, and other appropriate tasks as applicable for the position.
• Participate in emergency management and response trainings, drills, and activities in accordance with facility policies and procedures.
• Comply with sign-in and sign-out procedures as set forth by the Detention Facility. Additionally, they will be required to wear an identification badge while at the facility and maintain all key control protocols.
• Obtain the Prison Rape Elimination Act (PREA) Training
• Three (3) to five (5) years related experience required;
• Associates or Bachelor’s Degree preferred.
• Experience in a Federally Qualified Health Center or Healthcare Setting preferred.
• Behavioral Health Aide, Mental Health Aide, Medical Assistant, Chronic Care professional, LPN, or RN preferred.
• Certified Application Counselor and/or SHIP certification experience preferred
• Must possess a valid driver’s license issued by the State of Montana.
Fluent in the English language. Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or complaints.
• Physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• The employee is regularly required to sit and use hands and fingers to operate computer;
• Frequently is required to reach with hands and arms;
• Must occasionally lift and/or move up to 50 pounds while transporting files, equipment, and supplies;
• Specific vision abilities required by this job include close vision and looking into monitors for extended periods of time and ability to adjust focus which permits the employee to perform computer procedures, and to produce and review a wide variety of documents, correspondence, reports and related materials in both electronic and printed form;
• Clarity of speech and hearing that permits the employee to communicate well with others;
• Mobility that permits the employee to move about in a variety of building settings;
Personal mobility that permits the employee to enter, operate and exit motor vehicles and travel to other clinic sites.
• Work indoors in climate-controlled environment 95% of the time.
• OSHA Exposure Category #2 (The normal work routine involves no exposure to blood, body fluids, or tissues, but exposure or potential exposure may be required as a condition of employment.)
• Hours may vary as medical services must be available twenty-four (24) hours per day, seven (7) days per week.
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