Care Specialist - Full-Time; 4405-215-N

Catholic Charities Brooklyn and Queens•New York, 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 JOB Under the direct supervision of the HH Team Supervisor, the Care Specialist has overall day-to-day responsibility and accountability for coordinating all aspects of care for assigned health home serving children members 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. Duties of the Care Specialist focus on integration and coordination of physical health, mental health and social service needs. The Care Specialist has to become 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 electronically monitors and tracks data regarding health home member and alerts all members of the Care Team when follow-up is required. Accountable for 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 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. 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. Ensures the availability of priority appointments for health home members to care services including physical, psychiatric, and substance abuse within their health home provider network to avoid unnecessary, inappropriate utilization of emergency room and inpatient hospital services. 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. Tracks and shares health home members’ information and care needs across providers by utilizing electronic databases and monitors outcomes and initiate changes in care, as necessary, to address health home members’ needs. Reassesses needs for Health Home services and reviews health home members’ historical or targeted clinical measurements (i.e. number of ER visits and inpatient psychiatric admissions). Completes contact notes, incident reports, and other required documentation and maintains accurate recordings in electronic case files in a requested timely fashion.

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.
The position requires a combination of skills in the areas of crisis intervention, time management, and psychosocial rehabilitation skills
Able to lift up to 10 pounds.
Able to travel to multiple locations as needed.

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 the full range of medical, behavioral health, substance use, social and psychosocial services in the community
Integration and coordination of physical health, mental health and social service needs
Active participant in all phases of care transition to assure that members receive all required mental and medical follow up care and services
Take action around re-engagement of members who have become lost to care
Electronically monitors and tracks data regarding health home member and alerts all members of 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 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
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
Ensures the availability of priority appointments for health home members to care services including physical, psychiatric, and substance abuse within their health home provider network to avoid unnecessary, inappropriate utilization of emergency room and inpatient hospital services
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
Tracks and shares health home members’ information and care needs across providers by utilizing electronic databases and monitors outcomes and initiate changes in care, as necessary, to address health home members’ needs
Reassesses needs for Health Home services and reviews health home members’ historical or targeted clinical measurements (i.e. number of ER visits and inpatient psychiatric admissions)
Completes contact notes, incident reports, and other required documentation and maintains accurate recordings in electronic case files in a requested timely fashion.