Community Care Coordinator - Community Care

Glens Falls Hospital•Glens Falls, NY

About The Position

The Community Care Coordinator (CCC) facilitates & coordinates services to identified patients to optimize health & well-being, and to maximize the effectiveness & efficiency of healthcare. The CCC works in collaboration with all physicians, health care providers, and other service providers to prevent fragmentation and meet patient specific and age-related needs. The CCC attends to the full range of patient needs, including but not limited to, general health, mental health, substance use & abuse, housing, nutrition, and leisure.

Requirements

Bachelor's degree (in Human Services, Public Health, nursing, social work or related field preferred)
Associate’s degree in a relevant field and at least 1 year of experience in healthcare settings, experience working with individuals with chronic medical conditions, behavioral health issues, and/or substance use disorders would be considered.
Bachelor of Social Work and experience in care management or Certified Case Management experience in a broad range of medical specialties including psychiatry.
Valid New York State driver’s license with no history of citations that reflect unsafe driving (e.g., DWI/DUI convictions, multiple speeding/unsafe driving citations), and must have reliable transportation
Licensure/registration with the New York State Education Department as relevant to specific discipline.
Excellent written and verbal communication skills
Strong understanding of general medical & psychiatric illness, diagnosis, & treatments.
Ability to observe and recognize changes in symptoms or behaviors
Familiarity with psychiatric medications and their effects.
Skilled in communicating clearly with individuals from diverse backgrounds and perspectives on patient care.
Capable of de-escalating and engaging positively with individuals in crisis, agitation, or challenging situations.
Effective time management and ability to handle multiple simultaneous demands.
Receptive to constructive feedback and committed to professional growth.
Proficient with PC applications (e.g., MS Windows, Word) strongly preferred.

Nice To Haves

Knowledge of local community resources, regulations, and best practices in care coordination appreciated.

Responsibilities

Conducting comprehensive assessments: (gathering information on the client's medical and behavioral health needs, social determinants of health (SDOH), activities of daily living, and existing support systems)
Developing person-centered care plans: In collaboration with the client, their family, and an interdisciplinary care team, create a personalized care plan that outlines goals, interventions, and expected outcomes. (The plan should be regularly reviewed and updated to reflect changing needs and preferences.
Facilitating communication and collaboration: Act as a liaison between the client, family, primary care providers, specialists, behavioral health professionals, and other service providers to ensure seamless communication and coordinated care.
Managing appointments and referrals: Coordinate scheduling appointments, procedures, and referrals to appropriate healthcare providers and specialists. Ensure timely follow-up on referrals.
Monitoring Client progress and adjusting care plans: Continuously monitor the client's progress toward achieving their health goals and make necessary adjustments to the care plan in collaboration with the care team.
Supporting transitions of care: Ensure smooth transitions between different care settings (e.g., hospital to home, primary care to specialty care) by coordinating communication, sharing vital information, and arranging necessary follow-up care and resources.
Addressing social determinants of health: Identify and connect clients with resources that address social needs, such as housing, transportation, food security, and financial assistance. This often involves linking clients to community resources and government benefit programs.
Educating and empowering clients and families: Provide education about health conditions, options, self-management strategies, and the healthcare system. Empower clients to actively participate in their care decisions and advocate for their needs.
Promoting self-management goals: Support clients in developing and achieving self-management goals related to their health and well-being.
Maintaining accurate and detailed records: Document all interactions with clients, care team members, and service providers accurately and in a timely manner using Netsmart, electronic health records (EHR) or other designated systems.
Preparing necessary reports: Prepare and submit reports as required by the health home program and regulatory bodies, such as the Department of Health (DOH) or Office of Mental Health (OMH).
Advocating for clients' access to services: Ensure clients receive the care and resources they need, advocating on their behalf when necessary to overcome barriers or facilitate access to services.
Providing emotional support and guidance: Offer support and guidance to clients and families navigating the healthcare system and coping with health challenges