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

Acmh•New York, NY

21h•Hybrid

About The Position

Responsible for the assessment and engagement of clients around health and wellness and the development of a comprehensive care plan. The Health Navigator/Care Coordinator will develop rapport with clients to engage them in improving their health and wellness, administer standardized health and psychosocial risk screenings, and utilize these screenings to identify interventions and develop a comprehensive care plan. This role involves collaboration with the care team to identify needs and develop plans for optimal health outcomes, implementing care plan tasks, and ensuring follow-up and continuity of care. The position also includes reviewing and updating care plans, documenting interventions in the EHR, addressing Gaps in Care with providers, conducting home visits, working with family members, providing transitional care post-hospitalization, reviewing complex cases with the multidisciplinary team, facilitating care delivery by scheduling appointments and arranging transportation, utilizing evidence-based practices like motivational interviewing, and identifying community resources. The role also involves administering CSD funds, participating in team meetings and clinical conferences, and attending in-service training.

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.