Care Specialist II - Full-time; 4405-205-N

Catholic Charities Brooklyn and Queens•New York, NY

1d•Hybrid

About The Position

Catholic Charities Brooklyn and Queens has been providing quality social services for over 125 years, offering numerous programs for various age groups and those with mental illness. The Care Coordination Program specifically works with Health Homes to deliver comprehensive, community-based services for adults with Medicaid and serious mental illness. This program ensures clients receive coordinated behavioral and physical health services while addressing social determinants of health. Care Specialists manage issues such as housing, food security, benefits, medication adherence, and linkage to community resources. This role focuses on the highest need population, Health Home Plus (HH+).

Requirements

Master’s degree in social work, psychology or a related health/human services field and one (1) year of Experience; OR
Bachelor’s degree in social work, psychology or a related health/human services field and two (2) years of Experience; OR
Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and two (2) years of Experience; OR
Bachelor’s degree or higher in ANY field with either: three (3) years of Experience, or two (2) years of experience as a Health Home care manager serving the SMI or SED population.
Skills in crisis intervention, time management, psychosocial rehabilitation skills.
CANS-NY certification.
Ability in linking clients to a broad range of services essential to successfully living in a community setting (e.g., medical, psychiatric, social, educational, legal, housing and financial services).
Excellent communication skills.
Cross-cultural competency, outreach, interviewing, listening, advocating, linking, negotiating, engagement, monitoring and clinical assessment skills are essential.
Excellent computer skills are necessary.
Knowledge of the community medical resources and their financial requirements.
Good oral and written communication skills.

Nice To Haves

Fluency in second language preferred

Responsibilities

Coordinate all aspects of care for assigned health home serving children members with complex medical and/or psychiatric co-morbid conditions.
Facilitate access to medical, behavioral health, substance use, social, and psychosocial services in the community.
Integrate and coordinate physical health, mental health, and social service needs.
Actively participate in all phases of care transition to ensure members receive required mental and medical follow-up care and services.
Take action around re-engagement of members who have become lost to care.
Electronically monitor and track data regarding health home members and alert the Care Team when follow-up is required.
Engage and retain Queens health home members in care.
Coordinate and arrange for the continuous provision of services.
Support adherence to treatment recommendations.
Monitor and evaluate member needs, including prevention, wellness, medical, specialist, and behavioral health treatment, care transitions, and social and community services.
Develop, manage, and coordinate a comprehensive individualized person-centered care plan in collaboration with members, families, and providers.
Ensure availability of priority appointments for health home members to care services within their health home provider network.
Promote evidence-based wellness and prevention by linking members with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other medical services.
Track and share health home members’ information and care needs across providers using electronic databases.
Monitor outcomes and initiate changes in care as necessary.
Reassess needs for Health Home services and review historical or targeted clinical measurements.
Complete contact notes, incident reports, and other required documentation in electronic case files in a timely fashion.
Complete CANS-NY training and examination to properly assess clients.
Conduct outreach via phone to health home members between visits to check on self-care, medication fills, treatment plans, schedules, visits, and tests.
Monitor that the health home member completes post-visit follow-up.
Conduct monthly face-to-face visits with clients/children and monthly follow-up (telephonic or face-to-face) with various providers/collaterals.
Aid members in identifying primary care physicians and multidisciplinary teams of medical, mental health, chemical dependency treatment providers, social workers, nurse’s nutritionists/dieticians, pharmacists, outreach workers including peer specialists and other care providers.
Refer Queens health home members to peer supports and coordinate peer supports, support groups, and self-care programs.
Assure timely and comprehensive transitional care from an inpatient facility to follow-up with post-discharge interventions.
Develop and maintain health home networks with primary medical and specialty practitioners, mental health providers, substance abuse service providers, community-based organizations, managed care plans, emergency rooms, hospitals, and residential/rehabilitation settings.
Utilize regional health information organizations (RHIOs) and other data systems to track and share health home members’ information and care needs across providers.
Monitor outcomes and initiate changes in care as necessary.
Provide prompt notification of an individual’s admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting and address immediate needs.
Utilize and electronically track all specialty medical, behavioral, and support service referrals made for health home members, and ensure that the member follows up and receives all of the care they need.
Track and arrange appointments, educate health home members, and coordinate all aspects of the member’s health and community services.
Provide direct service provision of services to the consumer based on needs as established and documented in comprehensive assessments and service plans.
Report to Behavioral Health Services Administration and/or Agency Administration issues that may have a negative impact on the reputation of the Agency, client and/or staff welfare or any corporate compliance issue.
Cooperate with any and all investigations conducted by the Agency, funding sources and any other authorized agencies/entities.