Health Home Care Coordinator

People USA•Kingston, NY

11h•Onsite

About The Position

People USA is hiring an Ulster County Health Home Care Coordinator in Kingston, New York. The coordinator works with Medicaid-enrolled people living with mental illness or multiple chronic conditions, helping them connect with local care and services. The role serves people with unmet mental health, addiction, or social determinant of health needs who may not engage with traditional systems of care. The coordinator works with participants and their care teams to identify goals and connect participants directly to needed supports, with the aim of improving health and well-being and reducing duplicate services, emergency department visits, and inpatient admissions. The position includes care-management outreach and engagement, person-centered and trauma-informed screenings, participant advocacy and peer support, systems navigation, wellness education, and coordination with community providers. It also involves documenting participant interactions in electronic and paper records, submitting monthly reports, maintaining files and databases, attending meetings and training, and completing related office duties. The schedule is Monday through Friday, 9:00 a.m. to 5:00 p.m. (40 hours per week), at $24.50 per hour.

Requirements

A master’s degree in a qualifying field and one year of qualifying experience; or a bachelor’s degree in a qualifying field and two years of qualifying experience; or a bachelor’s degree or higher in any field and either three years of qualifying experience or two years of experience as a Health Home care manager serving the SMI or SED population; or CASAC credential and two years of qualifying experience.
Qualifying fields include social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing, or another human services field.
Qualifying experience must include direct services to people with serious mental illness, developmental disabilities, alcoholism or substance use, and/or children with SED; or linking these populations to services essential to successful community living, such as medical, psychiatric, social, educational, legal, housing, and financial services.
Thorough understanding of recovery for people diagnosed with psychiatric disabilities.
Knowledge of the ADA, mental health laws and systems, Social Security programs, work incentives, entitlement programs, supported employment, and federal, state, and local services, laws, and systems relating to people with disabilities.
Ability to recognize when participants need connections to services and facilitate those connections.
Knowledge of local, statewide, and national disability-related issues and community dynamics.
Excellent written and verbal presentation skills.
Ability to obtain NYS Peer Specialist Certification within six months of active employment.
Valid and clean driver’s license.

Nice To Haves

Personal experience as a recipient of mental health services and/or personal recovery experience is preferred.

Responsibilities

Assist participants with psychiatric diagnoses in accessing diverse, person-centered, self-directed services and meaningful activities that promote empowerment and recovery.
Collaborate with the Single Point of Access (SPOA) on referrals.
Maintain regular contact with participants and provide outreach, curriculum development, group facilitation, counseling, mentoring, systems navigation, community oversight, and crisis support.
Provide care-management outreach and engagement to eligible individuals in coordination with the Institute of Family Health and Care Management Partners of Ulster County.
Conduct screenings and evaluations using trauma-informed, person-centered skills and the Institute of Family Health’s service tools; provide individual advocacy, peer support, and systems navigation.
Educate participants on health and wellness topics, including peer and self-help resources, smoking cessation, and advocacy.
Provide education and support concerning recovery from mental health challenges, wellness and whole health, community resources, trauma and healing, wellness planning and prevention, and natural supports.
Help participants identify barriers to recovery or wellness, including access to care, quality of care, rights, unmet basic needs, stigma, and discrimination.
Advocate alongside participants to address barriers and ensure their voices, decisions, and rights are respected.
Build peer-to-peer relationships based on mutuality, shared lived experience, empathy, and hope for recovery and wellness.
Help participants identify and achieve whole-health goals across the eight dimensions of wellness.
Connect participants directly to needed services and supports through bridging and linking, rather than relying on referrals alone.
Develop and maintain positive working relationships with provider agencies and local housing providers, including landlords.
Document meaningful participant interactions in electronic records software and maintain hard-copy participant files for audit purposes.
Submit monthly reports on time and attend related meetings.
Represent the rights and interests of people living with mental illness or trauma by addressing barriers to recovery and wellness.
Conduct one-to-one and group peer-support sessions that encourage positive change and help participants feel better.
Support and guide participants as they access community resources related to health, wellness, and quality of life.
Use Epic Compass Rose regularly for documentation and billing requirements.
Assess whole-health and wellness needs, educate participants about internal and external community resources, link them to those resources, and work to ensure quality, integrated care.
Assist participants with health-care questions and needs related to stress, appointments, medications, food, transportation, housing, health insurance, and other services.
Maintain timely and accurate documentation, files, and databases; compile and submit program statistics and reports; attend weekly supervisory meetings; and participate in mandatory professional development and training.
Align work behaviors with trauma-informed care, customer engagement and satisfaction, mutuality, empathy, and the belief that everyone can and will recover.
Perform other duties as they arise.