Health Home Plus Care Coordinator

Jewish Family Service•Buffalo, NY

1d•$27 - $29

About The Position

The Care Coordinator-HH+ works with an assigned caseload of clients who are enrolled in the health home program and qualify for Health Home Plus (HH+). The Care Coordinator- HH+ is responsible for delivering an enhanced level of care coordination services to HH+ clients, including at least two (2) face-to-face visits per month and two (2) other core services. Clients enrolled in HH+ may also be enrolled in the Health and Recovery Plan (HARP). For HH+ clients that are also enrolled in HARP, the Care Coordinator- HH+ also assists with accessing Home and Community Based Services (HCBS) and Community Oriented Recovery and Empowerment Services (CORE). The Care Coordinator-HH+ conducts the NYS Eligibility Assessment, develops, and maintains the HCBS Plan of Care, and links clients to HCBS and CORE providers in the community. The Care Coordinator- HH+ also provides education to clients about HARP benefits and assists other care coordinators at JFS with linking their HARP enrolled clients to HARP services.

Requirements

Bachelor's degree in any of the following: child & family studies, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreation therapy, rehabilitation, social work, sociology, or speech and hearing AND
Two (2) years of experience providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism, or substance abuse, and/or children with SED
Bachelor's level education or higher in any field with three years of experience working directly with persons with behavioral health diagnoses
Bachelor's level education or higher in any field and two (2) years of experience as a Health Home care manager serving the SMI or SED population.
Exhibited ability to effectively work within an inclusive and culturally and linguistically diverse environment.
Strong internet research and computer skills, especially with Outlook, Word, Excel, PowerPoint, and web-based health information systems.
English speaking and writing fluency required.
Demonstrate basic knowledge of chronic conditions, including chronic mental conditions, HIV/AIDS, and serious mental illness.
Judgment and Decision Making - Considers relative pros and cons of potential actions to choose the most appropriate one.
Time Management – Uses time effectively and efficiently; values time; concentrates efforts on the more important priorities; gets more done efficiently and effectively.
Communication Intelligence - Listens to others, able to communicate issues clearly and credibly with widely varied audiences and overcome resistance; fosters open communication and manages emotion in positive ways
Adaptability & Flexibility - Adapts to changing business needs, conditions, and work responsibilities
Client Focus - Understands and meets customer needs, whether internal or external, providing a high level of service and cooperation courteousness & sensitivity)
Initiative & Adaptability - Deals with situations and issues proactively and persistently, personal willingness and ability to respond to change and ability to meet deadlines.
Must have access to a reliable vehicle, possess a valid, clean NYS driver’s license and be sufficiently self-insured with liability insurance in the amount of $100,000/$300,000.

Nice To Haves

Bilingual skills desirable.

Responsibilities

Maintain a caseload of clients enrolled in Health Home Plus (HH+) and HARP and provide care coordination services in compliance with health home policy and standards of care.
Work with the program manager to determine and establish HH+ eligibility for each client on their assigned caseload.
Conduct home visits with clients and travels into the community to meet with clients in other community-based settings, including medical provider appointments, hospitals, residential settings, and other community service provider offices.
Conduct comprehensive assessment and develop a patient-centered Plan of Care to address client needs. Assist clients with achieving their goals, in accordance with the Plan of Care.
Complete crisis plan with all client on assigned caseload and review with client at least annually.
Conduct annual case review with client and members of the client’s care team to review the Plan of Care and address barriers that prevent client from meeting their Plan of Care goals.
Successfully complete the HARP Assessment training in the Uniform Assessment System for New York (UAS-NY). Performs HARPs assessments/reassessments; maintains an active Health Commerce System (HCS) account.
Monitor the delivery of HCBS services to ensure clients are following through with goals identified in their HCBS care plans.
Assist client with coordination of appointments including but not limited to scheduling, rescheduling, providing appointment reminders and arranging transportation.
Works closely with the interdisciplinary care team including primary care providers, medical specialists, mental health providers, residential services, substance abuse treatment program, etc.
Conduct research on community resources and government benefit programs to determine eligibility criteria, provide appropriate referrals, and perform follow up activities for referrals.
Utilize culturally sensitive and linguistically appropriate strategies to engage and deliver services to clients.
Accurately document all interactions with clients and all efforts made towards client engagement. Submit all progress notes within 48 hours of the client encounter.
Collaborate and case conference with the MCO HARP Care Manager, HCBS, and CORE providers to ensure on-going client linkage and engagement in HCBS and CORE.
Effectively utilize electronic systems, including Netsmart, HEALTHeLink, PSYCKES, and ePACES.
Provide education to other members of the Care Coordination Division team on HARP, HCBS, and CORE and assists with transferring of newly HAREP enrolled clients between caseloads as needed.
Attend agency and department in-service training and staff meetings as well as any other agency related activities as required.
Effectively support health home programs on an as needed basis.