Care Coordinator DOH - Full-time; 4401-205-T

Catholic Charities Brooklyn and Queens•New York, NY

22h

About The Position

For over 125 years, Catholic Charities Brooklyn and Queens has been providing quality social services to the neighborhoods of Brooklyn and Queens, and currently offers 160-plus programs and services for children, youth, adults, seniors, and those struggling with mental illness. The Care Coordination program offers services to adults and children ages 6 to 18 enrolled in the Coordinated Behavioral Care (CBC) Health Home Program with a history of serious mental illness and/or multiple hospitalizations. The goal is to connect clients and families to various community resources identified as beneficial to the clients’ overall holistic well-being in order to reduce emergency room visits, inpatient stays and criminal justice involvement. STATEMENT OF THE JOB Under the direct supervision of the Team Supervisor, the Care Coordinator has overall day-to-day responsibility and accountability for coordinating all aspects of an assigned Department of Health clients’ care with complex medical and/or psychiatric co-morbid conditions and for facilitating their access to the full range of medical and psychosocial services in an efficient and effective manner. Care Coordinator responsibilities are consumer-centered, recovery-oriented activities in order to increase individuals’ capacity to manager their health and wellness, live a self-directed life and reach their full potential. The duties of the Care Coordinator are to focus on integration and coordination of physical health and mental needs of DOHMH consumers. The Care Coordinator has to become an active participant in all phases of care transition to assure that enrollees received all required mental and medical follow up care and services and re-engagement of consumers who have become lost to care. One of the many goals of Care Coordination efforts is a high-quality, timely, safe, effective and equitable referral or transition.

Requirements

Bachelor’s degree in social work, psychology or a related health/human services field with two years of direct work with the target population or Certification in Health profession field.
Combination of skills in the areas of crisis intervention, time management, and psychosocial rehabilitation skills.
Able to link clients to a broad range of services essential to successfully living in a community setting (e.g., medical, psychiatric, social, educational, legal, housing and financial services).
Ability to work flexible hours and days – including weekends/evenings/holidays according to needs of a 24/7 program.
Able to travel to different locations throughout the five boroughs as needed.

Nice To Haves

Knowledge of the second language is preferred (Spanish, Russian, Creole, Cantonese).

Responsibilities

Accountable for engaging and retaining individuals in care, coordinating and arranging for the continuous provision of services, supporting adherence to treatment recommendations, monitoring and evaluating their needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions and social and community services where appropriate through the creation of an individual plan of care.
Contact assigned individuals at a minimum for 2 face-to-face visits per month (recommended) to 4 or more face-to-face visits per month based on client need as established and documented in Comprehensive Assessments and Service Plans.
Reassesses needs for services and reviews consumers’ historical or targeted clinical measurements (i.e. number of ER visits and inpatient psychiatric admissions). Identifies potential barriers to successful care and resolutions to those barriers. Re-evaluate and adjust Comprehensive Assessments and Service plan for the consumer every 6 months or as needed (as per SOMH CAIRS requirements).
Follow- up with rehabilitative, long term care and social service needs and clearly identifies the primary care physician/nurse practitioner, specialists, behavioral health care providers, care manager and other providers directly involved in the individual’s care.
Promotes evidence based wellness and prevention by linking consumers with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other medical services based on individual physical needs and preferences.
Completes contact notes, incident reports, and other required documentation and maintains accurate recordings in electronic case files in a requested timely fashion.