Peak Vista Community Health Centers is a non-profit health care organization whose mission is to provide exceptional health care to people facing access barriers through clinical programs and education. We provide integrated health care services including medical, dental and behavioral health through our 22 outpatient health centers. We deliver care with our strong "Hospitality" culture. Our organization has over 800 employees and serves more than 81,500 patients annually in the Pikes Peak and East Central regions of Colorado. Our service area covers 14 counties, from the front range to the Kansas border, with locations throughout Colorado Springs, Fountain, Flagler, Divide, Limon and Strasburg. Peak Vista is accredited by the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC).

Compensation (Pay): $21.11 to $30.61/hourly, based on experience.

Summary of Benefits:

• Medical, Dental, Vision, Life, STD, LTD
• 403(b) Retirement with Company Match
• Paid Time Off
• Tuition Assistance
• Perks Rewards
• Employee Assistance Program

https://www.peakvista.org/resources/benefits-summary

Job Summary: Helps provide access to the right care, at the right time, in the right order, in the right setting with the right documentation. Works as a liaison between all modes of care. Responsible for working with the whole Care Coordination team in an interdepartmental effort to wrap around high-risk patients. Responsible for assisting high-risk patients in achieving maximum wellness through a collaborative, interdisciplinary process involving the patient, family and/or caregivers as well as providers and other support staff. This process includes assessment, planning, facilitation and advocacy through communication and the identification of available resources. Assists high-risk patients in identifying and obtaining services necessary to meet their overall needs and goals. This will in turn promote quality and cost-effective outcomes. High-risk factors may include more than one of the following:

• Age
• Poor pain control
• Previous home health and durable medical equipment usage
• Lack of social support
• Suicide Risk
• Chronic, catastrophic, terminal illness
• History of abuse, neglect
• Homelessness
• Transitional needs
• Poor nutritional status
• Financial concerns
• Repeated emergency department visits and/or hospitalizations
• Low functional status or cognitive deficit
• Co-morbid health conditions
• Mental illness or substance abuse
• Pervasive history of Guideline Non-Adherence
• Other identified high risk factors

Essential Duties and Responsibilities:

• Assesses clients’ psychosocial needs including health literacy status and care deficits (safety concerns and home layout barriers) and makes the appropriate referral for services.
• Assesses patient’s willingness to change.
• Coordinates service planning with client, family, or caregivers to maximize health care responses.
• Facilitates access to quality and cost-effective care.

• Coordinates and follows-up on referrals. Advocates and builds rapport with community agencies.
• Coordinates communication with members of the health care team and educating the client, family or caregiver and care team about treatment options and community resources as well as psychosocial needs and socioeconomic status and deficits.
• Coordinates care with the Emergency Diversion team.
• Involves possibly driving to client’s homes for assessment and follow-up and accompanying patients to off-site appointments as needed.
• Providing resource coordination, follow up, patient education, and self-management education services to patients and to serve as a consultant to medical staff and requesting support from professional staff when required.
• Operates corporate and/or personal vehicles, if applicable, in a safe and professional manner at all times. Travels to any/all of Peak Vista’s facilities as needed.
• Promotes and demonstrates the mission, vision, and Core Values of Peak Vista.
• Develops and maintains good working relationships with all departments, the management team, medical staff, and leadership.
• Embraces cultural diversity amongst ourselves and our community.
• Responsible for the human, financial, and material resources as well as data and information entrusted to us.
• Strives to deliver the best outcomes and highest quality service.
• Demonstrates knowledge of and adherence to the Compliance Plan and conflict of interest requirements.
• Enhances the effectiveness; efficiency and productivity of the department by contributing to, and participating in, departmental performance improvement goals.
• Other duties as assigned.

Supervision Exercised: None

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Spanish bilingual preferred.

Education/Experience:

Education: Minimum 4-year degree in human service field or related medical field OR equivalent experience required.
Work Experience: Three years’ experience in case management, crisis intervention or client-centered counseling and extensive knowledge of community resources required.