Health Home Care Coordinator
Position Title: Care Coordinator
Reports to: Local Program Coordinator
Supervisory Responsibilities: None
Provides support for designated clients which includes coordinating an array of services designed to
improve the health of high needs, high risk clients. Care coordination responsibilities will include
assessment, care planning and monitoring of client status, and implementation and coordination of
services. Provides support to clients for effective care transitions, improved self-management skills and
enhanced client-provider communication. Will facilitate interdisciplinary consultation, collaboration and
care continuity across care settings. This position will not involve providing direct care or treatment.
• Engages clients in care coordination activities designed to promote improved utilization of
health care services, including the creation and ongoing maintenance of a patient-centered, goal
oriented Health Action Plan.
• Assesses activation level for self-care through use of the Patient Activation Measure® (PAM®).
• Provides evidence-based health assessments and screenings such as; BMI, PHQ-9, Katz ADL, PSC17, GAD-7, AUDIT or DAST.
• Provides transition support services that coaches the client to build confidence and competence
in four conceptual areas, or “pillars”: medication self-management, use of a patient-centered
health record, primary care and specialist follow-up, and knowledge of red flags of their
condition and how to respond.
• Performs facility visits, home visits, and follow up telephone calls to develop critical coaching
relationships, to empower clients to take an active and informed role in their discharge
• Coordinates and communicates regarding the client’s post-discharge status with all involved
health care providers including, but not limited to: primary care, mental health, specialty care,
• Identifies and addresses barriers to overcome impediments to accessing health care and social
• Provides referrals and advocacy for clients and their caregivers to community based services and
• Provides teaching about self-management of the client’s chronic health condition and provides
resource links to ongoing chronic disease self-management support services.
• Develops and maintains complete and concise client files in compliance with policy to
appropriately document activities performed for the client and all elements required for specific
• Maintains all required documentation related to services provided and conforms to monthly
• Participates in staff meetings, public education and provider training sessions, as appropriate.
• Develops and maintains relationships with community agencies and organizations that have the
potential to provide resource support to the program or individuals.
• Prepares correspondence, memos, and client related written materials, as appropriate.
• Participates in continuing education and training programs.
• Works collaboratively with multi-disciplinary teams involving nurses, case managers and case
• Attends required meetings and trainings.
Knowledge, Skills, and Abilities:
• Direct functional assessment, service planning and implementation experience.
• Demonstrated client advocacy skills and sensitivity to the needs and values of diverse groups.
• Knowledge of the long-term care system and services, issues related to aging and disability, and
• Knowledge of local in-home and community options and resources for the elderly and adults
with disabilities and their caregivers.
• Ability to communicate verbally in the English language in face-to-face one-on-one settings, in
group settings, by personal computer, or using a telephone.
• Ability to work independently in the field, with good judgment and a minimum of supervision.
• Ability to work effectively as a team member with a wide range of diverse staff and community
members and to establish and maintain effective working relationships.
• Work effectively with colleagues and other customers by practicing punctuality, respect for
deadlines, collaborative problem solving and honest communication.
• Build trusting relationship by acting with integrity, courtesy and responsibility, even in the face
of stress or demanding workplace conditions.
• Ability to plan, organize, prioritize and coordinate work assignments and/or projects.
• Ability to work under pressure, within short timelines to implement service plan.
• Ability to establish and maintain effective working relationships with clients, families, caregivers,
diverse service provider network, medical personnel, and Agency staff.
• Ability to defuse difficult situations recognizing the need for sensitivity as well as assertiveness.
• Demonstrated ability to maintain a high level of confidentiality.
• Computer and software skills including Word, Excel and database systems; ability to operate
general office equipment; work at a desk using phone and computer for up to a full day’s work
• Ability to produce written documents with clearly organized thoughts using proper English
sentence construction, punctuation, and grammar.
• Ability to maintain paper and electronic records and files of clients and services provided and to
report those accordingly.
• Display empathy and positive regard for others in written, verbal and non-verbal
• Ability to operate standard office equipment.
• Demonstrated strength in learning and mastering new job responsibilities.
• Ability to function in a multi-lingual, multi-cultural environment, including providing service with
use of interpreters.
• Ability to travel to and from client’s homes and other community agencies which might not be
• Bachelor's degree in Social Work, Social Science, Gerontology, Psychology, Counseling, or related
fields and Two years of direct service case management or social service program experience
preferred. (Experience may be paid or volunteer experience within a social service agency.)
• Bilingual in English and Spanish preferred.
• Training in Coleman CTI or other coaching modality is desired.
• Experience working on cross disciplinary, cross-organizational teams is desired.
• Experience meeting and working with people in homes and other medical and community
settings is desired.
• Experience using motivational interviewing or other empowerment-based approaches is
• Possession of a valid driver’s license and minimum state-required vehicle insurance and have
use of reliable transportation.
• Successful completion of criminal background check.
Working Conditions and Physical Effort:
• While performing assessments in varied residential environments, the employee travels by
automobile and is exposed to changing weather conditions.
• A portion of the work is in a typical interior/office work environment with significant travel to
complete home visits.
• While performing the duties of this position, the employee is regularly required to talk, hear,
stand, walk, sit, stoop, use hand to finger, handle or feel objects, tools, or controls, grasping and
reach with hands or arms.
• The employee occasionally lifts or moves up to 25 pounds and/or a negligible amount of force
frequently or constantly to lift, carry push, pull or otherwise move objects.
• Specific vision abilities required by this job include close vision and the ability to adjust focus.
Repetitive motions to operate computer equipment while typing on keyboard and viewing
• Duties are performed in an office setting and include daily home visits to clients and their
families where conditions of the home environment may not be always be ideal or predicted.
• Some homes are potentially hazardous, to include unrestrained animals, inadequate housing
situations, clients or family members with hostile behaviors and second hand tobacco smoke.
• Driving conditions may be in rural settings and case managers may have home visits scheduled
during inclement weather.
• Requires being to work in a timely fashion, able to respond to public with good customer service
skills, ability to exercise good judgment as it relates to client care, following rules and
• Reasonable accommodations may be made to enable individuals with disabilities to perform the
Date: February 20, 2019
The statements contained herein reflect general details as necessary to describe the essential functions of this job, the level of knowledge and skill typically required and the scope of responsibility, but should not be considered an all-inclusive listing of work requirements. Individuals may perform other duties as assigned including work in other functional areas to cover absences or relief, to equalize peak work periods or otherwise balance the workload.
Southeast Washington Aging & Long Term Care is an equal employment opportunity employer.
SE WA ALTC ensures equal employment opportunities regardless of a person’s sex, race, national origin, religion, age, disability, marital status, creed, political belief, sexual orientation, veteran’s status or any other protected status under federal or state statute. Disabled applicants may request accommodation to participate in the job application and/or selection process for employment. In compliance with the Immigration Reform and Control Act of 198, SE WA ALTC will only hire United States citizens and aliens lawfully authorized to work in the United States.