Intensive Care Coordinator, Health Home Plus

NADAP Careers•New York, NY

About The Position

The Intensive Care Coordinator (ICC) in our Health Home Plus program provides assessment, care planning, and service coordination activities for eligible clients, with significant behavioral health, mental health, and/or medical needs. The ICC works closely with other health and social service providers to ensure comprehensive and appropriate care needs are met to stabilize participants, promoting access to health and wellness while reducing healthcare costs.

Requirements

Bachelor’s Degree in Social Work, Human Services, or related field required
Degree in social work, public health, or mental health counseling preferred with two years of experience or a master's degree with one year of experience.
Requires advanced knowledge of specialized or technical field or a thorough knowledge of the practices and techniques of a professional field.
May require knowledge of policies and procedures, and the ability to determine a course of action based on these guidelines.
Caseloads may flex based on need and acuity of targeted population.
Flexibility in caseload management required.

Responsibilities

Monitor progress of each client on an ongoing basis through delivery of face-to-face, escort, written, electronic, and telephonic outreach/monitoring/collaboration and planning activities, in accordance with Health Home Plus, DOH, OMH, and departmental guidelines.
Complete client-centered comprehensive functional assessments to identify the medical, behavioral health, and social needs/goals of each client.
Develop, adhere to, and document a daily schedule of appointments; inform supervisor of scheduling conflicts or changes and maintain an accurate record of daily activities.
Participate in individual and group supervision as scheduled by the appointed supervisor.
Develop, review, and update written/electronic person-centered care plans that are driven by functional assessment outcomes.
Share and develop/update care plans in partnership with the client and their Health Home network partners and collateral supports.
Ensure that all Care Plans uphold the policy and procedure set forth by the department and Health Home Plus.
Maintain an accurate caseload panel through prompt identification and response to cases appropriate for level of care changes, including but not limited to discharge or transfer activities.
Maintain collaborative relationships with all service providers utilized in the care planning interventions, sharing/extracting regular status updates and participating in case conferences as needed (and as outlined in the policy and procedure of the department and lead Health Home providers) to monitor level of care and health status for all assigned members.
Promptly review and address any crises that arise for any client with supervisory staff, service network and any involved legal entities.
Provide services to clients as needed to meet Care Plan objectives, including facilitating referrals to medical, behavioral health and social assistance entities; assisting with management of entitlements (Medicaid, SNAP benefits, SSI, etc.); assisting with securing stable housing; and arranging transportation and other services to support wellness and health care compliance.
Utilize Electronic Health/Medical Record system(s) of assigned Health Home and NADAP database tools to maintain documentation and all relevant treatment records, entering contact notes within the timeframe outlined in the Program Manual guidelines.
Performs other duties as assigned.