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

Catholic Charities Brooklyn and Queens•Queens, NY

2d•Hybrid

About The Position

Catholic Charities Brooklyn and Queens provides comprehensive care coordination and case management services for individuals with serious mental illness, complex medical needs, and substance abuse issues. The Care Coordination Program works with Health Homes to deliver community-based services for adults with Medicaid and serious mental illness, ensuring access to coordinated behavioral and physical health services while addressing social determinants of health. Care Specialists assist clients with issues such as housing, food access, economic security, medication adherence, and linkage to community resources and social supports. This position specifically works with the Health Home Plus (HH+) population, which represents the highest need group.

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, and psychosocial rehabilitation.
CANS-NY certification.
Ability to link 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.
Excellent computer skills.
Knowledge of community medical resources and their financial requirements.
Good oral and written communication skills.

Nice To Haves

Fluency in a second language.

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.
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/caregivers, and service providers.
Ensure the 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.
Complete CANS-NY training and examination.
Conduct outreach via phone to health home members between visits.
Monitor that health home members complete post-visit follow-up.
Conduct monthly face-to-face visits with clients/children and monthly follow-up with various providers/collaterals.
Assist health home members in identifying primary care physicians and multidisciplinary teams.
Refer Queens health home members to peer supports and coordinate peer supports, support groups, and self-care programs.
Ensure timely and comprehensive transitional care from inpatient facilities to 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 member information and care needs across providers.
Ensure prompt notification of an individual’s admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting.
Utilize and electronically track all specialty medical, behavioral, and support service referrals made for health home members.
Ensure members follow up and receive all necessary care.
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 established and documented in comprehensive assessments and service plans.
Work schedule includes holiday coverage to accommodate the coverage needs of the program when required.
Provide 24 hours/seven days a week availability for information and emergency consultation services.
Provide escorts to health home members from ER, hospital, and other settings to alternative levels of care.
Report to Behavioral Health Services Administration and/or Agency Administration issues that may negatively impact the agency’s reputation, client/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.