Care Specialist II - Full-time; 4405-211-N

Catholic Charities Brooklyn and Queens•Queens, NY

About The Position

For over 125 years, Catholic Charities Brooklyn and Queens has been providing quality social services to the neighborhoods of Brooklyn and Queens and currently offers 160-plus programs and services for children, youth, adults, seniors, and those struggling with mental illness. The Care Coordination program offers services to adults and children ages 6 to 18 enrolled in the Coordinated Behavioral Care (CBC) Health Home Program with a history of serious mental illness and/or multiple hospitalizations. The goal is to connect clients and families to various community resources identified as beneficial to the clients’ overall holistic well-being in order to reduce emergency room visits, inpatient stays and criminal justice involvement. STATEMENT OF THE JOBUnder the direct supervision of the HH Team Supervisor, the Care Specialist II has overall day-to-day responsibility and accountability for coordinating all aspects of care for assigned health home clients living with complex medical and/or psychiatric co-morbid conditions and for facilitating their access to the full range of medical, behavioral health, substance use, social and psychosocial services in the community, in an efficient and effective manner. This includes providing direct services to the specialty population of clients designated as Health Home Plus (HH+), which is an intensive health home care management service for individuals requiring more intensive and frequent visits in the community. This included working with clients who are court ordered to Assisted Outpatient Treatment (AOT). Duties of the Care Specialist II focus on integration and coordination of physical health, mental health, substance use and social service needs. The Care Specialist II must adhere to OMH guidelines and service delivery requirements for serving adults with Serious Mental Illness (SMI) and who meet certain indicators for high need, such as risk for disengagement from care and/or poor outcomes (e.g., multiple hospitalizations, incarceration, and homelessness). The Care Specialist II must be an active participant in all phases of care transition to assure that members receive all required mental and medical follow up care and services and must also take action around re-engagement of members who have become lost to care. The Care Specialist II may have a caseload of strictly HH+ clients or may have a mixed caseload of HH+ and non HH+ clients. The Care Specialist II electronically monitors and tracks data regarding health home member and alerts all members of the Care Team when follow-up is required. Health Home clients are visited in their home/community and live throughout Brooklyn and Queens. Accountable for engaging and retaining health home members in care, coordinating and arranging for the continuous provision of services, supporting adherence to treatment recommendations, monitoring and evaluating their needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care.Provide monthly Face to face visit(s) with client as well as monthly follow up (telephonic or face to face) with various providers/collaterals. HH+ clients must have 4 encounters monthly, 2 of which are face to face. All AOT clients must receive 4 or more face to face visits monthly. Outreach via phone to health home members between visits (check on self-care, medication fills, treatment plan, schedules visits, tests/follow-up) Monitors that the health home member completes post-visit follow-up (fill prescriptions, make appointments).Complete required assessments (initial appropriateness screening, comprehensive assessment, continued eligibility screening tool, annual assessment) to develop Care Plan. For AOT clients- complete weekly notes and significant events in AOT portal. Complete monthly service verifications with assigned AOT monitor. In collaboration with the health home members, their family and/or caregivers, and other service providers develops, manages and coordinates a comprehensive individualized person-centered care plan that coordinates and integrates the continuum of medical, behavioral health services, rehabilitative, long term care and social service needs and clearly identifies the primary care physician/nurse practitioner, specialists, behavioral health care providers, care manager and other providers directly involved in the individual’s care.Completes contact notes, incident reports, and other required documentation and maintains accurate recordings in electronic case files in a requested timely fashion. Promotes 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 based on individual physical needs and preferences.

Requirements

A Master’s degree in one of the qualifying fields (noted below) and one (1) year of Experience; OR A Bachelor’s degree in one of the qualifying fields and two (2) years of Experience; OR A Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and two (2) years of Experience; OR A 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.
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).
Must have excellent communication skills.
Cross-cultural competency, outreach, interviewing, listening, advocating, linking, negotiating, engagement, monitoring and clinical assessment skills are essential.
Ability to work flexible hours and days – including weekends/evenings/holidays according to needs of a 24/7 program.
Able to lift up to 10 pounds.
Able to travel to multiple locations as needed.

Nice To Haves

Fluency in second language preferred

Responsibilities

Accountable for engaging and retaining health home members in care, coordinating and arranging for the continuous provision of services, supporting adherence to treatment recommendations, monitoring and evaluating their needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care.
Provide monthly Face to face visit(s) with client as well as monthly follow up (telephonic or face to face) with various providers/collaterals.
HH+ clients must have 4 encounters monthly, 2 of which are face to face. All AOT clients must receive 4 or more face to face visits monthly.
Outreach via phone to health home members between visits (check on self-care, medication fills, treatment plan, schedules visits, tests/follow-up)
Monitors that the health home member completes post-visit follow-up (fill prescriptions, make appointments).
Complete required assessments (initial appropriateness screening, comprehensive assessment, continued eligibility screening tool, annual assessment) to develop Care Plan.
For AOT clients- complete weekly notes and significant events in AOT portal. Complete monthly service verifications with assigned AOT monitor.
In collaboration with the health home members, their family and/or caregivers, and other service providers develops, manages and coordinates a comprehensive individualized person-centered care plan that coordinates and integrates the continuum of medical, behavioral health services, rehabilitative, long term care and social service needs and clearly identifies the primary care physician/nurse practitioner, specialists, behavioral health care providers, care manager and other providers directly involved in the individual’s care.
Completes contact notes, incident reports, and other required documentation and maintains accurate recordings in electronic case files in a requested timely fashion.
Promotes 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 based on individual physical needs and preferences.