JOB
Under the general direction of the Public Health Supervisor, the Community Care Connector assures that members receive the services necessary to meet their needs and experience smooth transitions between care settings. Connectors also assure that communication between care settings and communication between South Country, County and community partners and resources occur in order to support member’s needs. Desired outcomes are attained through collaborative problem-solving approaches.The Connector works to assure a collaborative approach between the South Country and County team members. The position will develop positive relationships with and between SCHA, County, local health care providers, nursing facilities and members. They will help to ensure timely and accurate communication between team members. The Connector serves as the South Country liaison within the community/county, working towards positive outcomes for the member and South Country. The position promotes preventive services, early intervention to members and utilizes referral services available throughout the county.
EXAMPLE OF DUTIES
Collaborate1. Assist in identifying moderate to complex members by informing South Country of members health issues;2. Assist in creating and maintaining reports and follow-up as requested by South Country.3. Promote early intervention and preventative services to members and importance of establishing care with a primary care provider.4. Work with South Country to ensure members appropriate use of the Emergency Department, hospitalization, and re-admissions to hospital through telephonic, written or face-to-face follow-up with members after discharge to promote provider follow-up.5. Collaborate with South Country to schedule and assist with the facilitation of the South Country meetings.6. Assist with transitions of care through working with discharge planners, providers, members and/or authorized representatives.• Communicate1. Reach out and follow up with members and connect members to resources.2. Document in TruCare members responses to outreach as directed by South Country3. Develop relationships with key community partners and resources Develop and maintain strong communication and relations with South Country and county entities.• Coordinate1. Organize and attend monthly interdisciplinary care team meetings.2. Refer members and/or families, county, providers, community resources to Member Services or other appropriate SCHA staff for benefit and issue resolution.3. Refer member issues to county staff and/or other agencies as needed to assure member’s access to community services and resources;4. Coordinate activities and information with the County Supervisor.• Other duties as assigned.PROFILE REQUIREMENTS: • Works as a team with South Country and County staff• Promotes SCHA policies and mission in performing all duties and responsibilities• Incorporates best practice into all process initiatives• Excellent communication skills• Working knowledge of community services and resources• Working knowledge of SCHA products and operations including the website.
SUPPLEMENTAL INFORMATION
Remote/Hybrid possible once meeting certain requirements & qualifciations.Skilled in: Evaluating and performing client health assessments; screenings and care planning.Writing individual health plans and health plans for at-risk clients in accordance with relevant rules and regulations and program policies and guidelines.Interpreting and applying polices, rules, guidelines and procedures pertaining to the planning and delivery of health care services.Evaluating, assessing and making nursing health care assessments.Providing skilled nursing care, immunizations, and/or health testing for clients.Basic math skills.Operating and using computers and office productivity software (e.g. word processing, email, presentational and spreadsheet applications, etc.) in. documenting and maintaining health records, files, forms and reportingTime management and group facilitation skills.Presentational skills.Educating and informing county residents, individuals and families concerning health issues, concerns, communicable disease prevention and control, nutrition, pregnancy, child development and infant care.Virtual and in-person communication, writing and interpersonal skills as applied to interaction with coworkers, supervisor, the general public, etc. sufficient to persuade and/or influence others in matters relevant to department operations and health issues.Flexibility in schedule for after business hours events.Essential knowledge and specialized subject knowledge required to perform the essential functions of the job: Principles, practices, issues, trends and techniques in the field of public health and nursing.Public health and nursing concepts, practices and trends related to public health; communicable diseases, their etiology, transmission, control, prevention and general epidemiology issues.Knowledge of public health programs, services, and assessment criteria/tools.Knowledge of nursing technical procedures, care, treatments and processes.Knowledge of current trends in the delivery of health care services and effective delivery of Public Health Nursing Services.Knowledge of emergency preparedness issues and processes within the County.Legislative rules and regulations pertaining and impacting public health issues, services and program activities.Community resources and related services within and outside of the County.Physical requirements associated with the position can be best summarized as follows: Medium Work: Exerting up to 50 pounds of force occasionally, up to 25 lbs frequently, and/or a negligible amount of force constantly to lift, carry, push, pull or otherwise move objects, including the human body. Unusual or hazardous working conditions related to performance of duties: Duties associated with the job involve travel and exposure to blood, body fluids, contagious diseases, sharps, public contact or other environmental risks requiring constant precautions and safety considerations when dealing with the public in their homes or in the community. Duties include responding to public health emergencies and being exposed to disease and contagious outbreaks. Risks and hazards can be minimized to some extent by risk management procedures, safety precautions/equipment, training and professional judgment.