Care Coordinator - Elder Services

Fountain House•New York, NY

2d•$31

About The Position

At Fountain House, we believe in the power of community to transform the lives of individuals with serious mental illness. Every day, thousands of members choose to come to Fountain House to contribute their talents, learn new skills, access opportunities, and form friendships. Members and staff operate successful employment, education, wellness programs and work as partners to perform all the functions that keep our community going. The Fountain House model has been replicated in more than 300 locations in 30 countries and 32 states and currently serves more than 100,000 people with mental illness worldwide. As originators of this approach, we provide leadership by constantly advancing the practice and by leading the conversation around mental health recovery. As a result, Fountain House has created a comprehensive Community System of Care. This includes Clubhouses in Manhattan, the Bronx, Hollywood, California and Care Management, Community-Oriented Recovery and Empowerment Services (CORES), and a large housing program ranging from 24-hour supervised residences to scattered site supported apartments. We are committed to reducing social isolation, advocating for mental health policy change, and driving solutions that empower our members. Fountain House’s Care Management is a Health Home Care Management Agency. We are the team helping individuals with Medicaid to work on person-centered goals and care management to ensure all their medical and psychiatric needs are being met in an efficient and effective manner. The Care Coordinator role in this team is responsible for coordinating health care and ensuring all needs are met for members in the community who have chronic medical and / or mental health conditions to ensure positive health outcomes, decreased redundancy of care, decreased hospitalizations, as well as secured and sustained social determinants of health such as benefits, food security and housing. The Care Coordinator assists clients in overcoming barriers to quality health care, striving to improve overall health outcomes, reducing avoidable Emergency Room (ER) usage and inpatient hospitalizations. The Care Coordinator is also responsible for connecting members to appropriate medical services, coordinating care with members’ providers and supports, supporting individuals to make well-informed choices regarding treatment and providing education & empowerment. The position involves telephonic care coordination, on-site service provision as well as visiting members in the community. Care Coordinators are also responsible for conducting required assessments for health home enrollment and ongoing services. We are currently launching an Elder Justice initiative, to fill a critical service gap at the intersection of aging, mental health, and justice. By building a scalable, community-based model that reduces isolation, prevents maltreatment, and promotes recovery, Fountain House will advance elder justice and set a new standard for supporting older adults with SMI, including financial literacy and benefits protection, digital literacy and online safety, and wellness outreach programs that reduce isolation and provide immediate peer support. This role in Care Coordination will support the individuals served by the Elder Justice initiative. Full-time Monday to Friday, 9am to 5pm

Requirements

Excellent verbal and written communication skills, including ability to effectively communicate with internal and external care teams
Excellent interpersonal skills and the ability to engage members effectively
Excellent computer proficiency (MS Office – Word, Excel, and Outlook)
Must be able to work under pressure and meet strict deadlines, while maintaining a positive attitude and providing high quality services
Ability to work independently and to conduct assignments to completion within parameters of instructions given, prescribed routines, and standard accepted practices
Bachelor’s Degree required.
3 years of experience in the mental health field or Health Home Care Management preferred

Nice To Haves

Bilingual, Spanish speaking is a plus.
Community Health Work certification preferred

Responsibilities

Outreach Determine member eligibility through ePaces or Medicaid Analytics Performance Portal.
Actively outreach eligible members through phone, zoom, or in person meetings.
Give educational presentations to a variety of Fountain House internal programs on care management services.
Enroll 5 members per month until capacity of 50 members (HARP and non-HARP) is reached. (subject to change)
Actively engage caseload in service provision in accordance with care plans.
Maintain documentation for enrollment including the DOH 5055, PSYCKES, Healthix, and withdrawal of consent.
Enroll member into Relevant (Electronic Health Record, EHR)
Maintain and update demographics in the electronic health records for each individual served quarterly including upload of eligibility verification
Document each and every service provided in progress notes entered no later than 48 hours after the encounter
Conduct State regulated Eligibility Assessments for HARP members in UAS-NY (New York State platform) and complete the Plan of Care for HCBS/CORES referrals within 60 days of enrollment and annually thereafter
Conduct initial and subsequent periodic needs assessments for care plans at initial enrollment meeting and every 6 months
Complete extensive trainings for, including but not limited to, Relevant EHR, PSYCKES, Medicaid Redesign, HCBS, CORES, Housing, Benefits, MAPP, UAS-NY, and weekly Health Home value add webinars
Use resources or insurance databases to connect members to quality medical and behavioral health providers and specialists
Connect members to supports for education, employment, legal, food insecurities, and other community supports
Apply for and/or maintain benefits such as Medicaid, Food Stamps (SNAP), Social Security, and Social Security Disability
Secure safe and affordable housing for low income, mental health (HRA 2010e, SPOA), and/or lottery apartments.
Complete applications for one shot deals to ensure housing stability when appropriate
Conduct case conferences with member, their service providers, and any consented supports
Accompany and support members to and during appointments when follow-up and advocacy is necessary for success
Assist with transitional care during and after hospitalizations, including but not limited to responding to hospitalization alerts within 48 hours, case conference with hospital and service providers, escort to and from the hospital and follow up appointments, increased reach out and service provision after hospitalization, alert services providers to hospitalization, assist in helping transition back to prior level of care
Assess safety and conduct safety planning as needed
Assist members in improving activities of daily living and goal setting, such as budgeting, hygiene, medication compliance, nutrition support
Assist members in accessing transportation, including obtaining half-fare cards, applying for Medicaid transportation (MAS) and ACCESS-A-RIDE
Improve health literacy and provide psychoeducation for health conditions
Assist members in reading and understanding health care materials
Connect individuals to long term care services, such as managed long term care plans and home health aide services
Assist members in managing chronic health conditions
Collaborate with support team including consented family members
Operate using social practice and relationship building within the care management model