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Overview Plans and implements population/disease management programs and related protocols/policies based on evaluation of clinical outcomes and staff practice patterns. Collaborates with staff to improve clinical outcomes. Provides expert consultations, staff development plans, and continuous quality improvement (CQI) strategies. Works under general supervision. What We Provide • Referral bonus opportunities, • Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays, • Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability, • Employer-matched 401k retirement saving program and opportunity for both pre- and post-tax contributions, • Personal and financial wellness programs, • Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care and commuter transit program, • Generous tuition reimbursement for qualifying degrees, • Supports the integration of evidence-based care practices into protocols/policies, consultation strategies, staff development plans, continuous quality improvement initiatives, and research., • Focuses on improving the patient’s experience of care (including quality and satisfaction) and reducing the need for hospitalizations and urgent care visits., • Ensures patient/family centered needs are addressed. Establishes and communicates protocols and standards of care for a cultural and demographic diverse patient/family population; provides intervention guidelines based on these population health needs., • Evaluates clinical outcomes data and analyzes practice patterns to promote organizational responses that meet the needs of the patients with specific complex and chronic illnesses., • Develops policies, standards and protocols for the application of evidence-based practice and evaluates their impact on care management outcomes., • Identifies and develops new programs designed to improve care outcomes for complex patients. Collaborates with program leadership in implementation and evaluation of such programs., • Collaborates with program leadership to identify, develop, implement and evaluate practice improvement plans., • Evaluates staff practice patterns on an individual and team level to identify gaps and improve communication skills and clinical practice. • Educates, mentors, coaches and develops clinical staff and integrates complex illness management expertise into practice to improve quality of care, reduce transition problems from hospital to home, and reduce hospitalization rates., • Performs telephonic and in-person clinical consultations as needed., • Provides clinical care in accordance with VNS Health policies, practices, procedures and Standards of Professional Practice. • Partners with the Research department to provide clinical expertise for the development, design and implementation of research proposals., • Plans, develops, and implements care management programs with key external customers • For Pediatric Palliative Care:, • Provides Pediatric End of Life Nursing Consortium (ELNEC) training for interdisciplinary clinical staff based on curriculum provided by ELNEC., • Collaborates with Community Pediatric Attending Physicians and key referral sources in all regions to facilitate admission of patients with complex and chronic illnesses to the Pediatric Palliative Care Program. Assist transfers of hospice eligible patients from the Pediatric Palliative Care Program to Hospice Care of choice., • Collaborates with Hospice program leadership in implementation and evaluation of patients transferred from Pediatric Palliative Care to Hospice., • Collaborates with Community Pediatric Attending Physicians, Hospice Physicians, families, and/or caregivers to assist transfers of hospice eligible patients from the Pediatric Palliative Care Program to the Hospice Care of choice., • Leads the Pediatric Palliative Care Interdisciplinary Team Meetings in all regions on a monthly basis., • Provides assistance to referral sources, families and VNS Health clinicians with the insurance covered services and utilization of the Key Provisions of the Affordable Care Act for Children., • Collaborates with management in implementation, evaluation, and transfer of eligible patients. • Collaborates with Clinical Education and Development staff in the development of educational seminars., • For WOCN:, • Develops and implements formalized disease and symptom management education programs for clinical staff based on evidence based guidelines and reimbursement regulations. Licenses and Certifications: License and current registration to practice as a Registered Professional Nurse in the State of New York within 6 mo. of hire requiredValid driver's license or NYS Non-Driver photo ID card, may be required as determined by operational needs.Clinical certification in a specific specialty, such as diabetes, oncology, wound/ostomy/continence etc. preferred Education: Bachelor's Degree in Nursing requiredMaster's Degree in Nursing preferred Work Experience: Minimum of five years clinical experience requiredExperience developing and delivering disease specific educational programs preferredEffective oral/written communication and interpersonal skills requiredProficient with personal computers, including Microsoft Office Word, Excel preferred Pay Range USD $98,200.00 - USD $130,800.00 /Yr. About Us VNS Health is one of the nation’s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us — we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.

A company is looking for a Telephonic Nurse Case Manager.Key Responsibilities Provide remote medical case management services to injured individuals Coordinate medical services and explore vocational options for injured workers Collaborate with claim examiners, employers, attorneys, and medical

A company is looking for a Tele-Health Nurse (LPN) to provide remote support to patients and healthcare providers. Key Responsibilities: Provide telephonic and electronic support to stakeholders to enhance medication adherence Coordinate the collection of patient-specific clinical data for regula

Job Description ABOUT US: Founded in 2022, ForzaCare is a purpose-driven organization that helps injured individuals recover faster and return to work safely through coordinated, clinically appropriate care. Our name reflects our mission - Forza means "strength," representing the power of our team, and Care reflects our compassion for those we serve. ForzaCare is proud to be part of Ethos Risk Services, a leading national provider of investigative and risk mitigation solutions. Together, we're expanding our reach and strengthening our ability to deliver exceptional service across the workers' compensation industry. Learn more about ForzaCare and Ethos partnership here. JOB SUMMARY: As a Telephonic Case Manager at ForzaCare, you'll play a vital role in coordinating care for injured workers, primarily through phone-based interactions. Their responsibilities encompass communication, documentation, collaboration, and support to facilitate recovery and a successful return to work. This role is ideal for licensed nurses or certified rehabilitation counselors. While prior experience in workers' compensation is strongly preferred, those who have it will find their background especially valuable in this role. KEY RESPONSIBILITIES: • Coordinate care between medical providers, employers, attorneys, insurance carriers, and injured workers via phone to discuss treatment plans, progress, and return-to-work strategies., • Develop, document, and monitor individualized recovery goals and return-to-work plans., • Provide consistent communication and detailed progress reports to clients and stakeholders., • Ensure all case management work meets or exceeds customer and compliance requirements., • Build and maintain strong relationships with clients, providers, and internal team members. QUALIFICATIONS: Education & Licensure: • Active Registered Nurse (RN) or Certified Rehabilitation Counselor (CRC) license with an associated college degree is required., • Additional certifications such as CCM, CIRS, or other case management credentials are preferred., • Must comply with all state-specific licensure and certification requirements., • Prior experience in workers' compensation case management is strongly preferred. Skills & Attributes: At ForzaCare, we look for professionals who embody our values and thrive in a collaborative, purpose-driven environment: • Motivated –You take pride in exceeding goals and continuously improving., • Organized – You can manage a fast-paced workload and multiple priorities with ease., • Collaborative – You communicate clearly and work well with diverse teams and stakeholders., • Committed – You uphold ForzaCare's mission to deliver high-quality, compassionate care and comply with all safety, ethical, and professional standards. ForzaCare is an equal opportunity employer that does not discriminate on the basis of religious creed, sex, national origin, race, veteran status, disability, age, marital status, color or sexual orientation or any other characteristic. Job Posted by ApplicantPro

HarmonyCares employs more than 200+ primary care providers to deliver patient-centered care under an integrated, team-based, physician-driven model. To bring personalized, quality-based healthcare to the home of patients who have difficult accessing care. Every patient deserves access to quality hea

A company is looking for a Remote Triage Nurse - Weekend Days - Licensed Practical Nurse - LPN - LVN. Key Responsibilities Conduct thorough telephonic assessments with proprietary tools Identify and address patient concerns and acute clinical issues in collaboration with providers Provide teleph

Job DescriptionSalary: $110,000 - $115,000 Annually Position: Registered Nurse (Home Care) Location: Manhattan, NY Company: Edison Home Health Care Edison Home Health Care, a leading home health care agency serving all five NYC boroughs, is seeking an experienced Registered Nurse for the Manhattan area. Join our dedicated team and provide compassionate care to patients in their homes. Key Responsibilities: • Patient Evaluation: Assess patients referred for home care to determine their eligibility and appropriateness for services., • Care Planning: Routinely evaluate patients and create or adjust the aide Plan of Care based on their needs., • Supervision & Counseling: Provide regular supervision and guidance to Home Health Aides, offering ongoing instruction and counseling., • Documentation: Complete and submit accurate documentation to the agency office promptly., • Communication: Foster continuous communication with agency personnel to ensure optimal patient care and customer satisfaction. Qualifications: • Education & Licensure: R.N. diploma from an accredited NLN program with a minimum of an associate degree (BSN preferred). Must have a current, valid, and unencumbered RN license or relevant credentialing., • Skills: Intermediate proficiency with computerized systems such as Microsoft Outlook, Word, Excel, HHA Exchange, and electronic/telephonic assessments., • Travel: Ability to travel by public transportation or private vehicle (travel reimbursement provided). Required Experience: • Minimum of 1 year of nursing experience., • Home care experience preferred., • Bilingual Spanish skills are a plus but not required. What We Offer: • Competitive Compensation: 110-115k salary. Weekly pay with direct deposit available and opportunities for advancement., • Health & Wellness: Comprehensive Health, Vision, and Dental insurance, including dependent health coverage. Health Savings Account (HSA), Flexible Spending Account (FSA), AD&D Insurance, Life Insurance, Short & Long Term Disability, and Employee Assistance Program (EAP)., • Retirement Benefits: 401K plan., • Work-Life Balance: Generous PTO, sick days, bereavement leave, 6 paid federal holidays, and 2 floating holidays., • Additional Benefits: Employee Discount Program, referral program, loan assistance, and paid orientation., • Travel Reimbursement Make a Difference with Edison Home Health Care! Ready to join a team that values your skills and dedication? Apply today and be a part of something meaningful. #RNBK

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 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. 1. A bachelor’s degree in one of the fields listed below1; or, 2. A NYS teacher’s certificate for which a bachelor’s degree is required; or, 3. NYS licensure and registration as a Registered Nurse and a bachelor’s degree; or, 4. A Bachelor’s level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses; or, 5. A Credentialed Alcoholism and Substance Abuse Counselor (CASAC). 1 Qualifying education includes degrees featuring a major or concentration in social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field AND two years of experience: 1. In providing direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or

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. 1. A bachelor’s degree in one of the fields listed below1; or, 2. A NYS teacher’s certificate for which a bachelor’s degree is required; or, 3. NYS licensure and registration as a Registered Nurse and a bachelor’s degree; or, 4. A Bachelor’s level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses; or, 5. A Credentialed Alcoholism and Substance Abuse Counselor (CASAC). 1 Qualifying education includes degrees featuring a major or concentration in social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field AND two years of experience: 1. In providing direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or

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. 1. A bachelor’s degree in one of the fields listed below1; or, 2. A NYS teacher’s certificate for which a bachelor’s degree is required; or, 3. NYS licensure and registration as a Registered Nurse and a bachelor’s degree; or, 4. A Bachelor’s level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses; or, 5. A Credentialed Alcoholism and Substance Abuse Counselor (CASAC). 1 Qualifying education includes degrees featuring a major or concentration in social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field AND two years of experience: 1. In providing direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or, 2. In linking individuals with Serious Mental Illness, developmental disabilities, or substance use disorders to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services). A master’s degree in one of the qualifying education fields may be substituted for one year of experience.

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Assesses, plans, and implements complex care management activities based on member activities to enable quality, cost-effective healthcare outcomes. Develops a personalized care plan / service plan for care members, addresses issues, and educates members and their families/care givers on services and benefit options available to receive appropriate high-quality care. • Develops and continuously assesses ongoing care plans / service plans and collaborates with providers to identify providers, specialist, and/or community resources needed to address member's unmet needs, • Coordinates and manages as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or services, • Monitors care plans / service plans and/or member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / unmet needs, • May identify problems/barriers for care management and appropriate care management interventions for escalated cases, • Reviews member data to identify trends and improve operating performance and quality care in accordance with state and federal regulations, • Reviews referrals information and intake assessments to develop appropriate care plans/service plans, • May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources, • Collaborates with healthcare providers as appropriate to facilitate member services and/or treatments and determine a revised care plan for member if needed, • Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators, • Provides and/or facilitates education to members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefits, • Partners with leadership team to improve and enhance care and quality delivery for members in a cost-effective manner, • May precept clinical new hires by fostering and building core skills, coaching and facilitating their growth, and guiding through the onboarding process to upskill readiness, • Provides guidance and support to clinical new hires/preceptees in navigating within a Managed Care Organization (MCO) and provides coaching and shadowing opportunities to bridge gap between classroom training and field practice, • Engages and assists New Hire/Preceptee during onboarding journey including responsibility for completing competency check points ensuring readiness for Service Coordination success, • Engages in a collaborative and ongoing process with People Leaders and cross functional teams to measure and monitor readiness, • Other duties or responsibilities as assigned by people leader to meet business needs, • Performs other duties as assigned, • Complies with all policies and standardsEducation/Experience: Requires a Degree from an Accredited School or Nursing or a Bachelor's degree in Nursing and 4 – 6 years of related experience. License/Certification: • RN - Registered Nurse - State Licensure and/or Compact State Licensure required, • For YouthCare Illinois plan only: Bachelor’s Degree and IL RN licensure required. Must reside in IL required Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

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