Care Coordinator-CN536501
hace 1 mes
New York
Job Description JOB SUMMARY: The Children’s Care Coordinator functions as a member of an interdisciplinary team to provide care coordination to a caseload of seriously emotionally disturbed children with multiple medical comorbidities and/or co-occurring trauma disorders and/or children with HIV. Advocates for and supports the member and possibly their family, engages with community agencies/health care providers and others on his/her behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations. ESSENTIAL JOB FUNCTIONS: Essential job duties but not limited to the following: (To perform this job successfully, an individual must be able to perform each essential duty listed satisfactorily with or without a reasonable accommodation. Reasonable accommodations may be made to enable qualified individuals with a disability to perform the essential duties unless this causes undue hardship to the agency.) • Conducts initial and ongoing comprehensive assessments and care plans of assigned members to assess needs, create goals and link to resources., • Provides coordination support through consultation, education, interventions, safety planning, and linking to resources to maintain focus on outcomes and best practices., • Participates in the development/documentation/review of care plan in consultation with other care team members to ensure focus on desired outcomes., • Use team-based communication strategies to close the loop on referrals, hospital follow-ups and any outstanding items identified in the member’s care plan., • Maintains effective communications with members, primary care physicians, substance abuse, and mental healthcare providers, family, collateral resources and other agency staff on behalf of members., • Maintains documents, records, statistics, and other related reports in an organized, timely, and accurate manner as per policy and procedure., • Coordinates care planning with other providers of services/ resources to ensure goal directed, collaborative care, including care transitions., • Attends and participates in team meetings to provide input/feedback around psychosocial and medical conditions conditions/comorbidities to review member status, update plans and goals, review outcomes to further program goals., • Acts as a resource/consultant to all team members on psychosocial, medical and/or substance abuse issues and resources., • Performs outreach activities in primary care sites, homes, hospitals, and neighborhoods., • Provides telephonic as well as face-to-face outreach, engagement, and service planning in the field., • Acts as a linkage to community services including medical, behavioral, residential, entitlement and any other needed services per interdisciplinary care plan., • Monitors overall service delivery to ensure coordination and continuity; advocates with service providers/resources as needed., • Provides crisis intervention and follow-up., • Committed to active promotion of ICL values and goals., • Working knowledge of computer software and electronic health record systems, • Demonstrated competency in written, verbal, and computational skills to present and document records in accordance with program standards., • Experienced in and demonstrated comprehensive understanding and working knowledge of the interdisciplinary planning process and the developmental treatment model., • Knowledge of Medicaid, Social Security and other entitlements preferred. QUALIFICATIONS AND EXPERIENCE: • A bachelor’s degree in one of the fields listed below1; or, • A NYS teacher’s certificate for which a bachelor’s degree is required; or, • NYS licensure and registration as a Registered Nurse and a bachelor’s degree; or, • A Bachelor’s level education or higher in any field with three years of experience working directly with persons with behavioral health diagnoses; health homes, care management or AND two years of experience: • In providing direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or TRAINING REQUIREMENTS** Specific training for Health Home Serving Children must be completed within 30 days of hire.