Health Homes Plus - Care Coordinator

Trinity Health•City of Troy, NY

30d•$22 - $32

About The Position

We are looking for an energetic individual to join our Health Home Care Management Team! The ideal candidate will be someone who exercises compassion and dedication to serving the High-Need Seriously Mentally Ill population. Our philosophy is that recovery happens through therapeutic relationships. The sooner we can connect individuals who need ongoing Care Coordination, the sooner the member can begin to reach his or her potential. This includes the promotion of preventative care to reduce preventable emergency department and inpatient utilization, as well as an opportunity to address any social determinants of health. Position Summary: The HH+ Care Coordinator will develop a professional and trusting relationship with the High-Need Seriously Mentally Ill (SMI) population and community providers to ensure coordination and collaboration of services supporting positive outcomes. The HH+ Care Coordinator is responsible to provide weekly intensive care coordination to members and their families, to include: care coordination and collaboration, advocacy, information/education, referral to community resources and providers, as well as visits to the member’s home. Upon enrollment, the HH+ Care Coordinator collects information via a comprehensive assessment that will support developing a comprehensive plan of care with the member. The assessment will include their medical and behavioral health needs, substance abuse, activities of daily living, their socio-economic and housing status, and provides an opportunity to understand their social determinants of health. Additional responsibilities include developing a person-centered care plan that coordinates and integrates a comprehensive array of a member’s needs and services in collaboration with an interdisciplinary care team. The aim is to assist the member in reaching optimal wellness and recovery.

Requirements

Bachelor’s degree in Human Services with minimum of two years’ experience, or a Master’s Degree in Human Services, with one year experience, working with individuals diagnosed with Mental Illness, Substance Use Disorders, or Developmental Mental Disabilities providing direct linkage to community supports is required.
A Bachelor’s degree in an unrelated field with at least five years of experience, working with clients with Mental Illness, Substance Use Disorders, or Developmental Disabilities.
Strong writing and communication skills are required, as well as knowledge of working with community agencies and managed care representatives.
A valid and insurable NYS Driver’s License.

Nice To Haves

Previous discharge planning, counseling, home care, and substance abuse treatment experience is desired.
Experience working with a diverse population and a strong understanding of multicultural issues is preferred.

Responsibilities

Conduct an assessment for the establishment of a person-centered care plan that coordinates and integrates a comprehensive array of a member’s needs and services in collaboration with an interdisciplinary care team.
Respect members right to self-determination and providing creative guidance to members to support their care plan.
Assist members through the healthcare system by acting as a patient advocate and navigator.
Links individuals to community resource to meet basic needs that influence health (i.e.: Housing, food, transportation, childcare, etc.).
Maintain weekly contact with Members, collaterals, care team participants, etc., to support continuity of care and the needs as identified in the Plan of Care.
Promotes clear communication amongst care team and treating clinicians by ensuring awareness regarding member care plans, to coordinate the exchange of information and identify other care requirements and needs.
Complete all documentation within required timeframes (as defined in CHC Policies). It is the expectation that all interactions with or on behalf of a Health Home Member be documented in the electronic health record and be unique and detailed.
Participate in and / or initiate provider meetings as needed to discuss the status of the member and any factors that may be serving as barriers to success.
Provide comprehensive transitional care from inpatient (or other care setting) to the next setting to ensure members are linked with necessary services upon discharge.
Be an engaged team member who supports colleagues and department needs. This includes participation in team and department meetings, as well as supervision.