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

Catholic Charities Brooklyn and Queens•Brooklyn, NY

23h•Hybrid

About The Position

Catholic Charities Brooklyn and Queens has been providing quality social services for over 125 years, offering more than 160 programs and services. They provide comprehensive care coordination and treatment for individuals with serious mental illness, complex medical needs, and substance use disorders. The Non-Medicaid Care Coordination Program, under the NYC Department of Health and Mental Hygiene, assists individuals who do not qualify for Medicaid but are living with serious mental illness. This program ensures clients receive uninterrupted and coordinated behavioral and physical health services, while also addressing social determinants of health like housing, food access, economic security, medication adherence, and linkage to community resources.

Requirements

Bachelor’s degree in social work, psychology, or a related health/human services field with 2 years of direct work with the target population OR Degree/Certification in Medical and Clinical Assistance or Health Professional field.
Skills in crisis intervention, time management, and psychosocial rehabilitation.
Ability to link clients to a broad range of services essential for community living (medical, psychiatric, social, educational, legal, housing, financial).
Excellent communication skills.
Cross-cultural competency, outreach, interviewing, listening, advocating, linking, negotiating, engagement, monitoring, and clinical assessment skills.
Knowledge of community medical resources and their financial requirements.
Excellent computer skills.
Ability to read and write in English.
Knowledge of computer programs (MS Word, Excel, PowerPoint, & Outlook).

Nice To Haves

Knowledge of a second language (Spanish, Russian, Creole, Cantonese).

Responsibilities

Coordinate all aspects of an individual's care with complex and/or psychiatric co-morbid conditions.
Facilitate access to medical and psychosocial services efficiently and effectively.
Provide care in the client's home/community at least twice monthly, or more frequently if needed.
Focus on integration and coordination of physical health, mental health, and overall social needs.
Actively participate in all phases of care transition to ensure required mental and medical follow-up care and services.
Re-engage patients who have become lost to care.
Electronically monitor and track individual data and alert the Care Team when follow-up is required.
Engage and retain individuals in care.
Coordinate and arrange for the continuous provision of services.
Support adherence to treatment recommendations.
Monitor and evaluate client needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social/community services.
Develop, manage, and coordinate a comprehensive individualized person-centered care plan in collaboration with the client, family/caregivers, and other service providers.
Ensure the availability of priority appointments for clients to care services, including physical, psychiatric, and substance use within their provider network.
Promote evidence-based wellness and prevention by linking health home members with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other medical services.
Track and share client information and care needs across providers using electronic databases.
Monitor outcomes and initiate changes in care as necessary.
Reassess needs for services and review clients’ historical or targeted clinical measurements.
Identify potential barriers to successful care and develop resolutions.
Complete contact notes, incident reports, and other required documentation.
Maintain accurate recordings in electronic case files.
Utilize technology and various web-based platforms for documenting progress notes and daily work activities.
Use equipment such as iPhones, tablets, Surface Pros and navigate various technology platforms and reporting systems.