• Job Description

  Req#: 5012684
  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 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.
  In addition, the Connector may provide case management support for members enrolled in the Special Needs BasicCare (SNBC) program. This includes assisting individuals with disabilities in accessing necessary medical, behavioral, and social services, and supporting their independence and quality of life through individualized care planning and coordination. This position may also provide additional case management services as needed for members enrolled in other managed care programs, based on county needs.Collaborate
  
  1. 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.
  Communicate
  
  1. Reach out and follow up with members and connect members to resources.
  2. Document in TruCare members responses to outreach as directed by South Country.
  3. Develop relationships with key community partners and resources.
  4. Develop and maintain strong communication and relations with South Country and county entities.
  Coordinate
  
  1. 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.
  Case Management for Special Needs BasicCare (SNBC)
  
  1. Conduct comprehensive assessments and reassessments for SNBC members with disabilities.
  2. Develop and implement individualized, person-centered care plans that reflect member goals, strengths, and needs.
  3. Coordinate medical, behavioral health, social, and community services to ensure integrated and member-centered care.
  4. Support SNBC members in navigating services that promote independence, housing stability, and overall quality of life.
  5. Monitor member progress, service delivery, and update care plans as needed.
  6. Advocate for SNBC members by collaborating with medical providers, county agencies, and community organizations.
  7. Maintain accurate and timely documentation in accordance with SNBC and Minnesota Department of Human Services (DHS) requirements.
  Other duties as assigned
  Essential knowledge and specialized subject knowledge required to perform the essential functions of the job:
  
  • Community health resources, social services, and healthcare systems
  • Care coordination, case management, and transitions of care
  • Health assessment tools and person-centered planning
  • Preventive health, communicable disease prevention, nutrition, pregnancy, and child development
  • HIPAA and other confidentiality regulations
  • Electronic health records and standard office software
  • Local, state, and federal health policies (including South Country and DHS guidelines)
  • Communication strategies with diverse populations
  
  Skilled in:
  
  • Conducting assessments and developing care plans
  • Coordinating care across medical, behavioral, and social services
  • Supporting members during care transitions and post-discharge follow-up
  • Promoting early intervention and connecting members to care
  • Educating individuals and families on health topics
  • Communicating effectively in-person and virtually
  • Using software for documentation, reporting, and scheduling
  • Accurately documenting interactions in systems like TruCare
  • Facilitating care team meetings and discussions
  • Managing time and adapting to changing priorities
  • Working flexible hours, including some evenings
  
  BA/BS or AA and Registered Nurse, licensed in Minnesota
  Registered Nurse, licensed in Minnesota; OR Social Worker; or Bachelor’s degree in a related field
  
  A valid MN Driver’s license.
  
  Required Minimum Work Experience in Addition to Formal Education/Training:
  No previous experience required beyond educational and/or certification requirements.
  *Preference given to candidates with two years of experience in assessment and care plan development in a home and community-based setting.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:
  This position may involve visits to homes or community settings that are unsafe or unsanitary, with potential exposure to secondhand smoke, pets, or illnesses. The role includes working with individuals who may be in crisis, experiencing mental health issues, or acting aggressively. Travel is required in various weather and road conditions, including rural areas. Some situations may be emotionally difficult, such as cases involving abuse, neglect, or end-of-life care. Safety, confidentiality, and infection control practices must always be followed.

• About the company

  Sibley County is a county in the South Central part of the US state of Minnesota.

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