Health Navigator/Care Coordinator, Care Management Services (CMS)

Acmh•New York, NY

29d•$58,095

About The Position

Position: Health Navigator/Care Coordinator, Care Management Services (CMS) Function: Responsible for the assessment and engagement of clients around health and wellness and the development of a comprehensive care plan. Reports to : Director, Care Management Services Location: Manhattan office with travel throughout Manhattan & lower Bronx Schedule: Mondays-Fridays (9:00am-5:00pm)

Requirements

B.A. or M.A. degree in social services or related field and two years of experience providing direct service in the human service field or nursing or CM/Service Coordination.
Strong written and verbal communication skills.

Nice To Haves

Bilingual English/Spanish preferred.

Responsibilities

Develops rapport with clients in order to engage them in improving their health and wellness.
Administers standardized health and psychosocial risk screenings according to Health Home protocols and timeframes.
Utilizes health screenings to identify interventions and develop a comprehensive care plan
Collaborates with members of the care team to identify needs and develop a plan to help client achieve optimal health outcomes.
Implements tasks outlined on the care plan and ensures follow up and continuity of care between client interactions.
Regularly reviews and updates the care plan to correspond with services being provided.
Documents all interventions and attempted contacts in the EHR in accordance with program standards.
Works in collaboration with care providers to address Gaps in Care
Assesses domiciled client’s living conditions by conducting home visits
Works with family members and other collaterals of the client’s choice to facilitate planning and delivery of care
Provides comprehensive transitional care following hospitalization events in accordance with ACMH Critical Time Intervention (CTI) Protocols.
Reviews new information and complex cases with PCP and multidisciplinary team and incorporates recommendations into the care plan.
Facilitates care delivery by scheduling appointments, obtaining necessary information, and arranging transportation.
Utilizes evidenced based practices, such as motivational interviewing, to empower clients to grow and attain goals.
Embraces the team model by collaborating with members of the team and providing support as needed
Identifies community resources and makes referrals as needed.
Supports client goals and serves as an advocate on client’s behalf
Administers CSD funds (Client Service Dollars) and submits required documentation
Regularly participates in team meetings and weekly clinical conference
Attends in-service training as requested
Duties as assigned by supervisor