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

Catholic Charities Brooklyn and Queens•New York, NY

1d•$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 (CBC) 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, with the goal of reducing emergency room visits, inpatient stays, and criminal justice involvement. Under the direct supervision of the Team Supervisor, the Care Coordinator is accountable for day-to-day coordination of assigned health home members’ care, particularly for members with complex medical and/or psychiatric conditions. The role facilitates access to medical and psychosocial services, integrates physical and mental health needs, supports care transitions and re-engagement of members lost to care, and electronically tracks member data and follow-up needs. The position includes direct services, community outreach, home visits, travel among locations, and availability for information and emergency consultation services in support of a 24/7 program.

Requirements

Bachelor’s degree in social work, psychology, or a related health or 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 to live successfully in a community setting, such as medical, psychiatric, social, educational, legal, housing, and financial services.
Excellent communication skills and good oral and written 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.
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; lift up to 10 pounds; climb stairs; 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 services, support adherence to treatment recommendations, monitor needs, and create individual plans of care.
Develop, manage, and coordinate person-centered care plans with members, families or caregivers, and providers, integrating medical, behavioral health, rehabilitative, long-term care, and social service needs.
Arrange priority appointments for physical, psychiatric, and substance abuse services within the health home provider network.
Link members with evidence-based wellness and prevention resources, including smoking cessation, diabetes, asthma, hypertension, self-help recovery, and other medical services suited to individual needs and preferences.
Reassess members’ needs for Health Home services and review historical or targeted clinical measurements, including 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 accurate electronic case files in a timely manner.
Conduct phone outreach between visits to check on self-care, medication fills, treatment plans, appointments, tests, and follow-up; monitor whether members complete post-visit follow-up.
Help members identify primary care physicians and multidisciplinary medical, mental health, chemical dependency, and social service providers to ensure needed services are received in accordance with their care plans.
Maintain security of data files and use approved data-encryption methods to protect personally identifiable information.
Refer members to peer supports and coordinate peer support, support groups, and self-care programs to improve knowledge, engagement, self-management, and treatment adherence.
Coordinate timely transitions from inpatient facilities and arrange post-discharge interventions and follow-up care to help prevent avoidable readmissions.
Develop and maintain networks with medical and specialty practitioners, mental health and substance abuse providers, community organizations, managed care plans, emergency rooms, hospitals, and residential or rehabilitation settings.
Electronically track specialty medical, behavioral, and support-service referrals; arrange 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 documented in comprehensive assessments and service plans; reevaluate and adjust services every six months or as needed under SOMH CAIRS requirements.
Provide holiday coverage when required; be available 24 hours a day, seven days a week for information and emergency consultation, 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 client or staff welfare, as well as corporate compliance issues, to Behavioral Health Services Administration and/or Agency Administration.
Cooperate with investigations conducted by the Agency, funding sources, and other authorized agencies or entities.

Benefits

Generous time off, including vacation, personal days, sick days, and annual paid holidays
Medical insurance
Dental insurance
Vision insurance
Retirement savings with Agency match
Transit benefit
Flexible Spending Account
Life insurance
Public Loan Forgiveness Qualified Employer
Training Series and other additional voluntary benefits