Job Details Job Location: 866 UN Plaza - New York, NY Position Type: Full Time Education Level: 4 Year Degree Salary Range: Undisclosed Job Shift: Day
Description
JOB SCOPE:
As a member of the Care Coordination team and under the supervision of the Program Supervisor, the Care Coordinator for Health Home Plus (HH+) is responsible for providing intensive services to members on court-ordered Assistant Outpatient Treatment (AOT) status. The HH+ Care Coordinator addresses all member needs, provides care plan updates, conducts outreach to members between visits, communicates regularly with collaterals, and complies with all statutory requirements of Kendra’s law. HH+ Care Coordinators advocate for and support members, engage with community agencies and healthcare providers, and ensure access to services that promote wellness, reduce emergency visits and hospitalizations, and keep members safe within the community.
ESSENTIAL FUNCTIONS:
- Coordinate care for a caseload of approximately 12 to 15 AOT mandated members, performing other duties aligned with program goals as assigned by the Director/Assistant Director.
- Provide face-to-face contact at least once per week.
- Communicate with managed care plans regarding their members.
- Collaborate with each member’s AOT worker, including timely submission of weekly reports, monthly status updates, and significant event reports.
- Comply with all statutory reporting requirements under Kendra’s Law.
- Ensure transitions and service engagement comply with the individual’s AOT order.
- Complete CAIRS assessments promptly.
- Maintain effective communication with primary and specialty care physicians, mental health and substance abuse providers, family, collateral resources, and other agency staff.
- Keep documents, records, statistics, and reports organized, timely, and accurate as per policies.
- Conduct initial and periodic needs assessments, considering barriers, assets, member and family preferences, language, literacy, and cultural considerations.
- Assist in developing and implementing care plans, helping members understand and follow them, and tailoring communication to health literacy levels.
- Record client progress based on measurable goals outlined in care plans.
- Help members access healthcare and social systems, including transportation arrangements and appointment scheduling, often accompanying them.
- Identify community resources, manage referrals, and coordinate follow-up and engagement activities.
- Support coordination of access to individual and family supports and resources.
- Assist members in managing daily routines related to healthcare, leveraging strengths, and addressing barriers.
- Conduct outreach and engagement to support continuity of care, re-engaging members who miss appointments or do not follow up.
- Provide crisis intervention and follow-up.
- Monitor member entitlements, insurance, and benefits to ensure they remain active.
- Advocate for members during crises.
- Collaborate with professionals to evaluate health conditions and assess needs.
- Be responsible for on-call duties 2 to 3 weeks per year.
- Manage wrap-around funds, metro cards, and checks for member purchases, obtaining necessary approvals in line with member goals.
Qualifications
EDUCATION AND EXPERIENCE: