Care Coordinators (Various shifts within NYC & LI Regions)
Location: Medford & Queens
Job Function: Provide care coordination and health promotion to individuals with severe mental illness and/or have 2 or more chronic health conditions. This will include linkage to behavioral, medical, residential, social, financial, and vocational resources; collateral contacts with both behavioral and medical treatment follow up with referral and treatment appointments, and education of health promotion and preventive care. The care manager will communicate with the treating clinicians to discuss enrollee’s care needs, conflicting treatments, change in condition, etc. which may necessitate treatment change (i.e., written orders and/or prescriptions).
Qualifications: Minimum of a Bachelor’s degree or a CASAC with at least 2 to 5 years of experience serving people with mental illness, developmental disabilities or alcoholism or substance abuse. Valid and clean NYS driver’s license preferred. Fingerprinting, criminal record check, and approval from NYS Office of Mental Health.
- Create an individual based care plan. The care plan will be developed based on the information obtained from a comprehensive health risk assessment used to identify the enrollee’s physical, mental health, chemical dependency and social service needs.
- Accountable for engaging and retaining health home enrollees in care, as well as coordinating and arranging for the provision of services, supporting adherence to treatment recommendations, and monitoring and evaluating the enrollee’s needs. The individualized plan of care will identify all the services necessary to meet goals needed for care management of the enrollee such as prevention, wellness, medical treatment by specialists and behavioral health providers, transition of care from provider to provider, and social and community services where appropriate.
- Provide comprehensive transitional care from inpatient to other setting. Schedule appropriate follow-up appointments with after care settings and ensure the individual remains in treatment.
- Provide Individual and family support.
- Provide outreach services by telephone and face to face contact o individuals who are not yet enrolled in HH services and consent them to the respective Health Home.
- Engage patients in care by phone, letter, HIT and community outreach at least once per quarter.
- Use health information technology to link services, document care management activities, and data collection for quality indicator measurement.
- Determine client’s Medicaid eligibility
- Create integrated care plan with client. Care plan will include physical, mental health, chemical dependency and social service needs. The plan will identify the care manager, all medical and behavioral treatment supports, and family supports
- Provide crisis intervention services when client emergencies arise (May include but not limited to phone and face to face contact.) Care manager may need to dispatch team member to hospital if client presents at emergency room and alternate services are appropriate)
- Provide education on preventive care
- Review and upload pertinent medical/behavioral information through the RHIO
- Document care plan, all contacts with client and follow up in Foothold and/or Care Management Software
- Conduct HARP eligibility screenings and assessments.
- Comply with agency Compliance Plan and False Claims Policy by preventing, detecting and reporting any potential healthcare abuse and fraud. Report any potential non-compliance and comply with all other federal, state and local regulations applicable to this job description.
- Utilize all agency based IT applications pertaining to this job description in a proficient manner.
- Remain current on changing developments in individual field of expertise.
- Perform all other job duties as assigned.
- Strong motivational interviewing skills
- Ability to create recipient-centered and strength-based plans of care
- Knowledge of the physical health care system and the substance abuse disorder care system
- Knowledge of evidence-based practices and best practices
- Ability to identify quality providers, such as; integrated dual disorder treatment, individual placement and support, wellness self-management, family education, assertive community treatment, critical time intervention, and medication management
- Knowledge of the social services system and how to access resources and stay up to date with changing rules regarding benefits and entitlements, housing, employment supports, transportation, and self help groups
- Knowledge of HIT systems such as Foothold, AWARDS; AVATAR, roster wrangler and GSI, Outlook and Microsoft Office.