Health Home Care Coordinator

Requisition ID
Employment Type
Full Time
Home Health
Hours Per Pay Period
CHI Franciscan St. Joseph Medical Center
Standard Hours
8:00am - 4:30pm
Work Schedule
8 Hour


CHI Franciscan Health has exciting and rewarding careers with competitive salaries and benefits. We are a family of hospitals, health care services, and medical providers delivering compassionate care to people throughout the South Puget Sound. We are part of Catholic Health Initiatives, one of the largest not-for-profit health care systems in the country.


Our mission is to deliver high quality care that meets our patients' medical needs while providing emotional and spiritual support to patients and their families. We believe this three-part approach — physical, emotional, and spiritual — is essential to healing the whole person. Come join our team!


Job Summary:


This job is responsible for working with members, providers and multi-disciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential.  Work is conducted in accordance with professional clinical standards and applicable accreditation/regulatory requirements.  An incumbent maintains an ongoing member caseload for regular management and outreach, and work is strongly focused on ensuring that members are on track to progress towards desired outcomes based on quality care that is medically-appropriate and cost-effective based on the severity of illness and the site of service. 

Care coordination is provided primarily through telephonic communication, home visits and/or direct face-to-face contact, and an incumbent uses motivational interview and clinical guideposts to educate, motivate and support change during member contacts.  Local travel (up to 40%) may be required, depending on the complexity level of assigned member cases.

Work also includes: 1) completing clinical assessments and determining qualification for case management services; 2) developing, implementing, modifying and monitoring a case management plan to address member needs and goals; 3) documenting services provided in accordance with established guidelines; and 4) coordinating integrated outpatient care, including assessing barriers to care and identifying community resources and specific wellness programs (e.g. asthma, depression disease management) appropriate to enhance the continuity of care for members. 

Work requires understanding of psychosocial and clinical education concepts, professional standards and accepted guidelines for patient care, community resources and applicable regulatory requirements.  Knowledge of transitional case management concepts, methodologies and tools is also required.  An incumbent uses the plan of care in giving members the tools they need to assist them in taking charge of their medical/psychosocial conditions to improve their overall health and quality of life, and to decrease the potential for hospital admissions/readmissions.


This supports the Pierce County Region.


Essential Duties:

Completes member screening within scope of experience, training, and expertise, and communicates social, emotional and patient/family stressors to interdisciplinary healthcare provider team as relates to member’s plan of care.

Coordinates with the member/family, the interdisciplinary healthcare provider team, insurance payers and community resources in organizing the outpatient care; promotes and facilitates effective chronic disease self-management and provides tools to assist members/families in achieving maximum levels of wellness and independence.

Serves as a member of the provider/interdisciplinary team and contributes to the development/modification of a comprehensive plan of care for assigned caseload of at-risk patients.

Monitors member’s progress towards achievement of self-management goals identified in the plan of care and provides ongoing status reports to management, provider team and/or other interested parties.

Documents services provided in accordance with Care Management Documentation Standards and actions taken in the medical record in a timely and comprehensive manner that reflects recognition of the legal significance of an accurate and complete record.

Researches and identifies community resources, vendors, medical supply companies, healthcare agencies and other resources appropriate to the patient’s individualized plan of care.

Additional Responsibilities:

Adheres to and exhibits our Core Values of Reverence, Integrity, Compassion and Excellence.


Education/Work Experience Requirements

Bachelor’s degree in social work, psychology, geriatrics, nursing, behavioral health or related field and one year of related work experience that would demonstrate attainment of the requisite job knowledge/abilities.  Work experience in case management, social work or discharge planning is preferred. 

An equivalent combination of post-secondary education and work experience that would demonstrate attainment of the requisite job knowledge/abilities may be substituted for the degree requirement.


Social Home Worker, Social Work , Social Services


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