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

Catholic Charities Brooklyn and Queens•Brooklyn, NY

About The Position

The Care Coordinator is responsible for the day-to-day coordination of care for assigned Health Home members with complex medical and/or psychiatric co-morbid conditions. Under the direct supervision of the Team Supervisor, the role facilitates members’ access to medical and psychosocial services and coordinates physical and behavioral health needs, care transitions, and follow-up. The program serves adults and children ages 6 to 18 enrolled in the Coordinated Behavioral Care Health Home Program who have a history of serious mental illness and/or multiple hospitalizations. Its goal is to connect members and families with community resources that support holistic well-being and help reduce emergency room visits, inpatient stays, and criminal justice involvement. The Care Coordinator engages and retains members in care, develops and coordinates individualized person-centered care plans with members, families or caregivers, and providers, and monitors members’ needs, referrals, appointments, treatment adherence, and transitions between care settings. The position also tracks relevant data electronically, documents services in electronic case files, helps members access community supports and benefits, and collaborates with a broad network of medical, behavioral health, social service, and community providers. The work schedule may include flexible hours, evenings, weekends, and holidays to meet the needs of a 24/7 program. The position also includes availability for information and emergency consultation services, and escorts for members transitioning from emergency rooms, hospitals, or other settings to an alternative level of care.

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; alternatively, a degree or certification in Medical and Clinical Assistance or a health professional field.
Skills in crisis intervention, time management, and psychosocial rehabilitation.
Ability to link clients with a broad range of services needed to live successfully in a community setting, including medical, psychiatric, social, educational, legal, housing, and financial services.
Excellent communication skills, including good oral and written communication.
Cross-cultural competency and skills in outreach, interviewing, listening, advocating, 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 and 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 continuous services, support adherence to treatment recommendations, and monitor and evaluate member needs.
Develop, manage, and coordinate individualized person-centered care plans with members, families or caregivers, and other service providers.
Coordinate medical, behavioral health, rehabilitative, long-term care, social service, and community services across the member’s care continuum.
Ensure access to priority appointments for physical, psychiatric, and substance abuse care within the Health Home provider network.
Link members with evidence-based wellness and prevention resources, including smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other medical services suited to their needs and preferences.
Reassess members’ needs for Health Home services and review relevant historical or targeted clinical measurements, such as 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, scheduled visits, 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.
Maintain the security of data files and use approved data encryption methods to prevent theft of personally identifiable information.
Refer members to peer supports, support groups, and self-care programs, and coordinate those supports to promote knowledge, engagement, self-management, and adherence to treatment.
Coordinate timely transitional care from inpatient facilities and post-discharge interventions to help prevent avoidable readmissions and ensure follow-up care.
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 and rehabilitation settings.
Electronically track specialty medical, behavioral health, and support service referrals and ensure members receive and follow up on needed care.
Track and 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 to consumers based on needs documented in comprehensive assessments and service plans, with services reevaluated and adjusted every six months or as needed under SOMH CAIRS requirements.
Provide holiday coverage when required and maintain 24/7 availability for information and emergency consultation services; escort members from emergency rooms, hospitals, and other settings to alternative levels of care.
Report issues that may negatively affect the Agency’s reputation, client or staff welfare, or corporate compliance to Behavioral Health Services Administration and/or Agency Administration.
Cooperate with investigations conducted by the Agency, funding sources, and other authorized agencies or entities.