Contentnea Health

Company Overview

Contentnea Health is a Community Health Center providing comprehensive medical, dental and behavioral health services for members of our communities in Greene, Pitt and Pamlico counties in eastern North Carolina.    

Job Summary

Collaborates with the health care team to coordinate care between behavioral health, primary care, and community-based services.
  

Responsibilities and Duties

1. Collaborates with interdisciplinary team to develop individualized care plans, track progress and support patient engagement in care.
   1. Works with providers and clinical staff to develop individualized care plans that align with patient needs, clinical recommendations, and available services.
   2. Supports integrated care delivery across primary care and behavioral health services.
   3. Participates in interdisciplinary case reviews.
   4. Monitors treatment progress and patient outcomes.
   5. Supports treatment adherence and ongoing engagement in services.
   6. Identifies and addresses barriers to patient’s participation in care.
   7. Documents all care coordination and patient activities in the electronic health record (EHR), ensuring documentation aligns with Health Resources Services Administration (HRSA), reporting, quality improvement, and billing requirements.
2. Coordinates seamless access to services through active coordination and communication.
   1. Manages internal and external referrals for behavioral health and community-based services within established guidelines.
   2. Facilitates warm hand-offs between providers and service partners.
   3. Connects patients to appropriate internal and external resources.
   4. Reduces gaps in care during critical transition points, including hospital discharges and specialty follow-ups.
   5. Coordinates post-discharge and follow-up services to promote continuity of care.
   6. Addresses potential barriers during transitions to prevent treatment disruption.
3. Collaborates with leadership to improve program performance, effectiveness, and support sustainability.
   1. Contributes to discussion related to strategic priorities and grant expectations.
   2. Supports compliance with grant, regulatory, and program standards.
   3. Supports quality improvement initiatives related to behavioral health services.
   4. Uses visual workflows and tools to support program structure and understanding.

Qualifications and Skills