Role Description The Care Coordinator is a trained professional that helps patients manage their chronic conditions by calling patients monthly. Monthly calls will include: - Assessing current health status - Educating patients about their chronic conditions - Answering questions and acting as a resource between the patient and the provider - Addressing any urgent patient needs - Following up on any changes in patient condition Job Duties & Responsibilities Include but are Not Limited to: - CCM monthly calls or verbal enrollments - Other services such as Health Risk Assessments, Transitional Care Management, Remote Patient Monitoring, etc. - Communicate with patients and family members about their chronic conditions, medications, quality measures, barriers to care, and practice-specific requests - Communicate effectively with providers, staff, and other healthcare professionals - Promote adherence to a care plan developed in coordination with the patient, primary care provider, and family/caregiver(s) - Increase patients’ ability for self-management and shared decision-making, and assist patients in reaching established goals - Medication reconciliation - Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing healthcare costs - Represent CCS in a caring and professional manner to providers and other healthcare professionals - Comply with organizational guidelines and healthcare laws and regulations, including CMS guidelines - Be flexible and a team player - Maintain expected call volume (see Call Expectations Policy) Qualifications - Unencumbered active CMA/RMA certificate or unencumbered active compact license LPN/RN - Active BLS certification - Ability to plan and organize time effectively, work independently, and show good judgment - Excellent problem solving, clinical reasoning, and critical thinking skills - Ability to communicate effectively both verbally and in writing - Knowledge of CCM regulations and of CCM billing requirements - High proficiency in working within EHR systems - Operational knowledge of Google Suite, Atlas, and other required software Home Office Care Coordinators must have a HIPAA compliant workplace that is free of any distractions. The workplace must include: - A room with a locked door to prevent accidental PHI disclosures - High-speed internet - A CCS-approved computer with two monitors Physical Demand Includes but is not limited to vision, hearing, repetitive motion, typing, and sedentary extended viewing of a work environment computer screen. Reasonable accommodations may be made, with advanced notice, to enable individuals with disabilities to perform the essential functions and expectations of the position without compromising patient care.

• Conduct comprehensive assessments including ASAM forms, biopsychosocial assessments, and applicable evaluations. • Identify treatment needs, integrating findings into a collaborative, measurable treatment plan with patients. • Document and update treatment plans and clinical records in adherence to program, regulatory, and confidentiality standards, maintaining accuracy and security. • Maintain regular contact with referral sources and family members to provide progress updates and facilitate support, offering consistent communication throughout the treatment process. • Lead and facilitate individual and group sessions, including daily process groups and multidisciplinary treatment reviews, promoting open self-disclosure and collaboration on patient needs and goals. • Coordinate resources and develop post-discharge plans to support patients with legal, financial, and vocational needs, ensuring comprehensive recovery planning. • Apply clinical judgment and intervention skills in crisis situations, including risk assessments, de-escalation, and suicide risk evaluations. • Adapt therapeutic approaches to meet diverse patient needs. • Build rapport and foster trust with patients through strong interpersonal skills, working effectively with diverse populations.

• Provides patient care modalities of evidence-based practices to best meet the clinical needs of the patients. • Review and signature of patient clinical Psychosocial assessment, diagnosis, treatment plan, and consents as needed for the patient in a timely manner. • Conducts crisis intervention for the individual and family based on the individual’s safety plan. • Participate in regular case planning with the involved Multidisciplinary Team as new information is gathered.

• Provides patient care modalities of evidence-based practices to best meet the clinical needs of the patients. • These specific treatment modalities will be implemented in both the individual and group therapy setting. • Review and signature of patient clinical Psychosocial assessment, diagnosis, treatment plan, and consents as needed. • Documents all services and patient activities appropriately. • Conducts crisis intervention for the individual and family based on the individual’s safety plan. • Participate in regular case planning with the involved Multidisciplinary Team. • Participate in individual and group supervision as required. • Provides case management services to promote recovery and community reintegration as needed.