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AOT Care Coordinator
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Full-time
- Guided by a ‘population health’ model of care, Essen has five integrated clinical divisions offering services in primary & specialty offices, urgent care centers, and nursing homes, as well as house calls for home bound patients; all clinical services are also offered via telehealth.
- Performs essential transitional care coordination services, including pre-release contacts, day-of-release warm handoffs, assessments and service planning, and assists with entitlements, housing, vocational rehabilitation, life skills, and reintegration services.
- Connects members to community support services and outpatient health services, including mental health, substance use, behavioral health, harm reduction and medical services.
- Leads and advocates for the member during crisis response, case conference and IDT meetings, when applicable.
- Documents all encounters and interventions timely and completes initial assessments, reassessments, service care plans, progress notes (using DAP format), and discharge plans.
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