Care Coordinator DOH - Full-time; 4401-204-N

Catholic Charities Brooklyn and Queens•New York, NY

4d•$30 - $34

About The Position

Catholic Charities Brooklyn and Queens’ Care Coordination program serves adults and children ages 6 to 18 enrolled in the Coordinated Behavioral Care Health Home Program who have a history of serious mental illness and/or multiple hospitalizations. The program connects clients and families with community resources that support holistic well-being and aims to reduce emergency room visits, inpatient stays, and criminal justice involvement. Under the direct supervision of the Team Supervisor, the Care Coordinator is responsible for day-to-day coordination of an assigned Health Home member’s care when the member has complex medical and/or psychiatric co-morbid conditions. The role facilitates access to medical and psychosocial services, coordinates physical and mental health needs, supports care transitions and re-engagement of members who have become lost to care, and electronically tracks member data and follow-up needs. The position also provides direct services, outreach, referral coordination, documentation, and transitional support. The schedule may include holidays and flexible hours, with availability for a 24/7 program as required.

Requirements

Bachelor’s degree in social work, psychology, or a related health/human services field and two years of direct work with the target population, or a degree/certification in Medical and Clinical Assistance or a health professional field.
Skills in crisis intervention, time management, and psychosocial rehabilitation.
Ability to link clients to a broad range of services needed for community living, including medical, psychiatric, social, educational, legal, housing, and financial services.
Excellent communication skills.
Cross-cultural competency and skills in outreach, interviewing, listening, advocacy, linking, negotiating, engagement, monitoring, and clinical assessment.
Excellent computer skills.
Knowledge of community medical resources and their financial requirements.
Good oral and written communication skills.
Ability to work flexible hours and days, including weekends, evenings, and holidays, according to the needs of a 24/7 program.
Ability to talk, hear, walk, stand, and sit regularly; lift up to 10 pounds; climb stairs and make home visits; stretch and bend to retrieve files; operate a computer keyboard, mouse, and office equipment; sit and work at a computer for long periods; and travel to multiple locations as needed.

Nice To Haves

Fluency in a second language.

Responsibilities

Engage and retain Health Home members in care; coordinate and arrange ongoing services, support adherence to treatment recommendations, and monitor and evaluate members’ needs through an individual plan of care.
Develop, manage, and coordinate comprehensive, individualized, person-centered care plans with members, families or caregivers, and service providers.
Coordinate physical health, behavioral health, rehabilitative, long-term care, and social service needs, and identify providers involved in each member’s care.
Ensure access to priority appointments for physical, psychiatric, and substance abuse care within the provider network.
Link members with evidence-based wellness and prevention resources, including smoking cessation, diabetes, asthma, hypertension, recovery, and other services suited to their needs and preferences.
Reassess needs for Health Home services and review relevant historical or targeted clinical measures, such as emergency room visits and inpatient psychiatric admissions.
Identify barriers to successful care and work toward resolving them.
Complete contact notes, incident reports, and other required documentation, and maintain timely and accurate electronic case files.
Conduct phone outreach between visits to check on self-care, medication fills, treatment plans, appointments, tests, and follow-up; monitor completion of post-visit tasks.
Help members identify primary care and multidisciplinary medical, mental health, chemical dependency, and social service providers.
Maintain the security of data files and use approved encryption methods to protect personally identifiable information.
Refer members to peer supports and coordinate support groups and self-care programs to strengthen knowledge, engagement, self-management, treatment adherence, and informed decision-making.
Coordinate timely transitional care from inpatient facilities and arrange post-discharge interventions to reduce avoidable readmissions and support follow-up care.
Develop and maintain networks with medical and specialty practitioners, mental health and substance abuse providers, community organizations, managed care plans, hospitals, emergency rooms, and residential or rehabilitation settings.
Electronically track specialty medical, behavioral, and support-service referrals; arrange and track appointments, educate members, and coordinate health and community services.
Ensure members’ entitlements, insurance, and benefits are in place, and provide interpreter services as required.
Provide direct services based on needs established in comprehensive assessments and service plans, reevaluating and adjusting services every six months or as needed under SOMH CAIRS requirements.
Provide holiday coverage when required, be available for information and emergency consultation services in a 24/7 program, and escort members from emergency rooms, hospitals, and other settings to alternative levels of care.
Report issues that may negatively affect the Agency’s reputation or the welfare of clients or staff, as well as corporate compliance issues.
Cooperate with investigations conducted by the Agency, funding sources, and other authorized entities.