Care Coordinator-CN536501

Institute for Community Living

About The Position

The Children's Care Coordinator functions as a member of an interdisciplinary team to provide care coordination to a caseload of seriously emotionally disturbed children with multiple medical comorbidities and/or co-occurring trauma disorders and/or children with HIV. Advocates for and supports the member and possibly their family, engages with community agencies/health care providers and others on his/her behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations. ESSENTIAL JOB FUNCTIONS: Essential job duties but not limited to the following: (To perform this job successfully, an individual must be able to perform each essential duty listed satisfactorily with or without a reasonable accommodation. Reasonable accommodations may be made to enable qualified individuals with a disability to perform the essential duties unless this causes undue hardship to the agency.) Conducts initial and ongoing comprehensive assessments and care plans of assigned members to assess needs, create goals and link to resources. Provides coordination support through consultation, education, interventions, safety planning, and linking to resources to maintain focus on outcomes and best practices. Participates in the development/documentation/review of care plan in consultation with other care team members to ensure focus on desired outcomes. Use team-based communication strategies to close the loop on referrals, hospital follow-ups and any outstanding items identified in the member's care plan. Maintains effective communications with members, primary care physicians, substance abuse, and mental healthcare providers, family, collateral resources and other agency staff on behalf of members. Maintains documents, records, statistics, and other related reports in an organized, timely, and accurate manner as per policy and procedure. Coordinates care planning with other providers of services/ resources to ensure goal directed, collaborative care, including care transitions. Attends and participates in team meetings to provide input/feedback around psychosocial and medical conditions conditions/comorbidities to review member status, update plans and goals, review outcomes to further program goals. Acts as a resource/consultant to all team members on psychosocial, medical and/or substance abuse issues and resources. Performs outreach activities in primary care sites, homes, hospitals, and neighborhoods. Provides telephonic as well as face-to-face outreach, engagement, and service planning in the field. Acts as a linkage to community services including medical, behavioral, residential, entitlement and any other needed services per interdisciplinary care plan. Monitors overall service delivery to ensure coordination and continuity; advocates with service providers/resources as needed. Provides crisis intervention and follow-up. May be assigned other tasks and duties reasonably related to the job responsibilities.

Requirements

Committed to active promotion of ICL values and goals.
Working knowledge of computer software and electronic health record systems
Demonstrated competency in written, verbal, and computational skills to present and document records in accordance with program standards.
Experienced in and demonstrated comprehensive understanding and working knowledge of the interdisciplinary planning process and the developmental treatment model.
Knowledge of Medicaid, Social Security and other entitlements preferred.
Excellent interpersonal skills.
Ability to regularly travel throughout all five boroughs using an agency vehicle if authorized, public transportation, or other means of transportation as appropriate.
A bachelor's degree in one of the fields listed below1; or A NYS teacher's certificate for which a bachelor's degree is required; or NYS licensure and registration as a Registered Nurse and a bachelor's degree; or A Bachelor's level education or higher in any field with three years of experience working directly with persons with behavioral health diagnoses; health homes, care management or A Credentialed Alcoholism and Substance Abuse Counselor (CASAC).
1 Qualifying education includes degrees featuring a major or concentration in social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field AND two years of experience: In providing direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or In linking individuals with Serious Mental Illness, developmental disabilities, or substance use disorders to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services).
A master's degree in one of the qualifying education n fields may be substituted for one year of experience .
Specific training for Health Home Serving Children must be completed within 30 days of hire.

Responsibilities

Conducts initial and ongoing comprehensive assessments and care plans of assigned members to assess needs, create goals and link to resources.
Provides coordination support through consultation, education, interventions, safety planning, and linking to resources to maintain focus on outcomes and best practices.
Participates in the development/documentation/review of care plan in consultation with other care team members to ensure focus on desired outcomes.
Use team-based communication strategies to close the loop on referrals, hospital follow-ups and any outstanding items identified in the member's care plan.
Maintains effective communications with members, primary care physicians, substance abuse, and mental healthcare providers, family, collateral resources and other agency staff on behalf of members.
Maintains documents, records, statistics, and other related reports in an organized, timely, and accurate manner as per policy and procedure.
Coordinates care planning with other providers of services/ resources to ensure goal directed, collaborative care, including care transitions.
Attends and participates in team meetings to provide input/feedback around psychosocial and medical conditions conditions/comorbidities to review member status, update plans and goals, review outcomes to further program goals.
Acts as a resource/consultant to all team members on psychosocial, medical and/or substance abuse issues and resources.
Performs outreach activities in primary care sites, homes, hospitals, and neighborhoods.
Provides telephonic as well as face-to-face outreach, engagement, and service planning in the field.
Acts as a linkage to community services including medical, behavioral, residential, entitlement and any other needed services per interdisciplinary care plan.
Monitors overall service delivery to ensure coordination and continuity; advocates with service providers/resources as needed.
Provides crisis intervention and follow-up.
May be assigned other tasks and duties reasonably related to the job responsibilities.