Care Coordinator-HH536580
9 days ago
New York
Job Description JOB SUMMARY: The Care Coordinator functions as a member of an interdisciplinary team to provide care coordination to a caseload of severely mentally ill adults with multiple medical comorbidities and/or co-occurring substance abuse disorders and/or medically ill individuals. Advocates for and supports the client, engages with community agencies/health care providers and others on his behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations. Provides clinical support to the Team by providing consultation, education, information around psychosocial and/or substance abuse conditions, interventions, resources to maintain focus on outcomes and best practices. ESSENTIAL JOB FUNCTIONS: List all essential job duties. (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 assessments of assigned clients to document strengths, needs, goals, and resources., • Participates in the development/documentation /review and update of client centered comprehensive integrated, interdisciplinary care plan in consultation with other team members to ensure focus on desired outcomes., • Maintains effective communications with clients, primary care physicians, substance abuse, and mental healthcare providers, family, collateral resources and other Agency staff on behalf of clients., • 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., • Works as part of a Care Coordination team; attends and participates in team meetings to provide input/feedback around psychosocial and medical conditions conditions/comorbidities to review client status, update plans and goals, review outcomes to further program goals., • Acts as a resources/consultant to all team members on psychosocial, medical and/or substance abuse issues and resources., • 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 clients to ensure coordination and continuity; advocates with service providers/resources as needed., • Provides crisis intervention and follow-up., • May be assigned other tasks and duties reasonably related to the job responsibilities., • 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., • Excellent interpersonal skills required., • Specific training for the designated assessment tool(s), the array of services and supports available, and the client-centered service planning process. Training in assessment of individuals whose condition may trigger a need for HCBS and supports, and an ongoing knowledge of current best practices to improve health and quality of life., • 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 five years of experience working directly with persons with behavioral health diagnoses; or AND two years of experience: • In providing direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or