Health Navigator/Care Coordinator (Non-BA), Care Management Services (CMS)

ACMH INC•New York, NY

8h•Hybrid

About The Position

The Health Navigator/Care Coordinator (Non-BA) within Care Management Services (CMS) is responsible for assessing and engaging clients in improving their health and wellness. This role involves developing comprehensive care plans, administering screenings, collaborating with care teams, and ensuring continuity of care. The position also includes conducting home visits, facilitating care delivery, utilizing evidence-based practices, and connecting clients with community resources. The role emphasizes a team-based approach and advocacy for clients.

Requirements

AA degree in social services or related field and one year of experience providing direct service OR a High School diploma/GED with four years’ experience 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 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 clients 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.
Performs duties as assigned by supervisor.