The Health Home Care Coordinator is responsible for gathering and processing information for the Health Home program from individuals, providing information and referrals for services, maintaining and monitoring program data, and reporting program-related data. Ensures program outcomes and objectives are being met, and ensures services provided meet organizational guidelines, funder requirements and accreditation standards.

This position fulfills the Health Home Facilitator role per DMH Health Home guidelines.

Essential Functions:

• Gathers, researches and processes Health Home program information from individuals for program enrollments, transfers and discharges. Responsible for ensuring all required information is obtained, verified and entered within established timeframes. Ensures all state requirements and internal standards are met before submitting information to DMH.
• Accesses multiple hospital data portals and reports to monitor program individuals' admissions and discharges. Obtains information, creates reports and communicates hospitalization information to nursing staff daily.
• Extracts metabolic screening values from electronic records and enters that information into DMH and internal systems. Monitors upcoming due dates for screens and communicates that information to nursing staff.
• Answers questions regarding the Health Home Program services. Evaluates individual's eligibility for community services and refers them to services as needed. Provides individuals with population-based healthcare materials based on individual need.
• Maintains multiple tracking systems in order to provide data to Health Home staff to better support individual needs and meet program goals. Maintains data in multiple systems and ensures that the data are accurate and up to date. Runs reports as scheduled and as requested.
• Manages census with breakdown of DM and slot availability. Researches and obtains outreach individual data for re-engagement of services.
• Identifies and researches high utilizers of emergency care for reporting purposes.
• Cross trains on all Health Home Care Coordinator tasks and maintains updated workflows for assigned tasks.

Qualifications:

• Must have high school diploma or equivalent. Bachelor's degree in human services or related field preferred.
• Must have at least 1 year of experience working with individuals with disabilities.
• Must have experience using Microsoft Office suite, and intermediate-level skill with Excel.
• Previous experience working with Electronic Health Record systems or other data systems preferred.