Care Specialist - Full-time; 4601-201-N

Catholic Charities Brooklyn and Queens•Queens, NY

2d•Hybrid

About The Position

Catholic Charities Brooklyn and Queens, with over 125 years of service, offers more than 160 programs and services for various age groups and needs, including mental illness, complex medical conditions, and substance abuse. The Children’s Care Coordination team, part of the New York State Health Homes Program, focuses on children and families aged 0-21. This program aims to help them achieve their goals and live well-cared for in the community by connecting them with tailored services to address healthcare needs and ensure access to timely and efficient community-based support.

Requirements

Bachelor’s degree in social work, psychology, or a related health/human services field with two (2) years of direct work with the target population.
OR Degree/certification in Medical and Clinical Assistance or Health professional field.
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 a second language is preferred.

Responsibilities

Coordinating all aspects of care for assigned health home serving children members with complex medical and/or psychiatric co-morbid conditions.
Facilitating access to medical, behavioral health, substance use, social, and psychosocial services in the community.
Integrating and coordinating physical health, mental health, and social service needs.
Assuring members receive required mental and medical follow-up care and services.
Taking action around re-engagement of members who have become lost to care.
Electronically monitoring and tracking data regarding health home members and alerting the Care Team when follow-up is required.
Engaging and retaining Queens health home members in care.
Coordinating and arranging for the continuous provision of services.
Supporting adherence to treatment recommendations.
Monitoring and evaluating member needs, including prevention, wellness, medical, specialist, and behavioral health treatment, care transitions, and social and community services.
Developing, managing, and coordinating a comprehensive individualized person-centered care plan in collaboration with members, families, caregivers, and service providers.
Ensuring the availability of priority appointments for health home members to care services within their network to avoid unnecessary emergency room and inpatient hospital utilization.
Promoting evidence-based wellness and prevention by linking members with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other medical services.
Tracking and sharing health home members’ information and care needs across providers using electronic databases and monitoring outcomes.
Initiating changes in care as necessary to address health home members’ needs.
Reassessing needs for Health Home services and reviewing historical or targeted clinical measurements.
Completing contact notes, incident reports, and other required documentation, maintaining accurate recordings in electronic case files.
Completing CANS-NY training and examination.
Conducting outreach via phone to health home members between visits.
Monitoring that the health home member completes post-visit follow-up.
Conducting monthly face-to-face visits with clients/children and monthly follow-up with various providers/collaterals.
Aiding health home members in identifying primary care physicians and multidisciplinary teams.
Referring Queens health home members to peer supports and coordinating peer supports, support groups, and self-care programs.
Assuring timely and comprehensive transitional care from an inpatient facility to follow-up with post-discharge interventions.
Developing and maintaining 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.
Utilizing regional health information organizations (RHIOs) and other data systems to track and share health home members’ information and care needs across providers.
Monitoring outcomes and initiating changes in care as necessary.
Providing prompt notification of an individual’s admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting and addressing immediate needs.
Utilizing and electronically tracking all specialty medical, behavioral, and support service referrals made for health home members.
Ensuring the member follows up and receives all necessary care.
Tracking and arranging appointments, educating health home members, and coordinating all aspects of the member’s health and community services.
Direct service provision of services to the consumer based on needs as established and documented in comprehensive assessments and service plans.
Providing holiday coverage as required by the program's needs.
Being available 24 hours/7 days a week for information and emergency consultation services.
Providing escorts to health home members from ER, hospital, and other settings to alternative levels of care.
Reporting issues that may negatively impact the agency's reputation, client/staff welfare, or corporate compliance to the Behavioral Health Services Administration and/or Agency Administration.
Cooperating with investigations conducted by the Agency, funding sources, and other authorized agencies/entities.