Children's Health Home Care Coordinator

Postgraduate Center for Mental Health; New York (NY); On-site; USD 52,000 - 72,000; Full time

Job summary

Postgraduate Center for Mental Health in New York City seeks a Care Coordinator to support Medicaid beneficiaries with chronic health and behavioral health needs through the Health Home model. You will work under the Program Supervisor to address member needs, update care plans, and coordinate with providers.

You will engage with members via in-person and outreach, maintain records, conduct needs assessments, and advocate for access to services to improve wellness and reduce ER visits.

Qualifications

• High School Diploma and CASAC plus four (4) years of related human services experience in providing direct services to individuals with chronic health and/or behavioral health disorders.
• Associate Degree in one of the listed fields plus three (3) years of related experience.
• Bachelor’s Degree in listed fields plus two (2) years of related experience.
• Master’s Degree in listed fields plus one (1) year of related experience.

Responsibilities

• Coordinate care for a caseload of 40-50 members.
• Maintain monthly contact with all members of assigned caseload.
• Engage with members through face-to-face, mail, electronic, and telephone contact.
• Communicate with physicians, substance abuse and mental health providers, and family.
• Maintain documents, records, statistics, and reports.
• Conduct initial and periodic needs assessments.
• Assist with care plan development and execution.
• Record client progress and measure goals.
• Assist with accessing healthcare and social systems; arrange transportation.
• Identify community resources; manage referrals and follow-ups.
• Assist with wrap-around funds and approvals for member purchases.

Education

High School Diploma and CASAC; Associate Degree in Human Services, Psychology, Rehabilitation, Nursing, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Health, Physical or Recreational therapy; Bachelor’s Degree in Social Work, Psychology, Education, Rehabilitation, Nursing, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Hearing, Physical or Recreational therapy; Master’s Degree in relevant field with related experience

Master’s Degree in Social Work, Psychology, Education, Rehabilitation, Nursing, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Health, Physical or Recreational therapy

Job description

JOB SCOPE:

As a member of the Care Coordination team and under the supervision of the Program Supervisor, the Care Coordinator is responsible for addressing all member needs, providing care plan updates and conducting outreach to members in between visits. Care Coordinators provide care coordination to NYC Medicaid beneficiaries with chronic health and/or behavior health disorders using a Health Home service model. Care Coordinators advocate and support members, engage with community agencies/health care providers and others on the member’s behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/or hospitalizations.

ESSENTIAL FUNCTIONS:

• coordinates care for a caseload of 40-50 members.
• maintains monthly contact will all members of assigned caseload, with increased contact for newly enrolled and high risk members;
• upon handoff from the Outreach Team, conduct member engagement activities, including face-to-face, mail, electronic, and telephone contact;
• establish and maintain effective communication with primary and specialty care physicians, substance abuse and mental healthcare providers, family, collateral resources and other agency staff on behalf of members;
• maintain documents, records, statistics, and other related reports in an organized, timely and accurate manner as per policy and procedure;
• conduct initial and periodic needs assessments, including assessing barriers and assets (i.e. transportation, community barriers, social supports); member and family/caregiver preferences and language, literacy, and cultural preferences;
• assist with the development and execution of member’s care plans, including assisting members in understanding care plans and instructions and tailoring communications to appropriate health literacy levels;
• record client progress according to measurable goals described in his/her care plan;
• assist members with accessing healthcare and social systems, including arranging for transportation and scheduling and accompanying members to appointments;
• assist members with identifying available community-based resources and actively manage appropriate referrals, access, engagement, follow-up, and coordination of services;
• Assist with coordinating members’ access to individual and family supports and resources.;
• assist members with managing daily routines related to healthcare and incorporating members’ strengths and identifying barriers;
• assist with conducting outreach and engagement activities that support continuity of care, including re-engaging members in care if they miss appointments and/or do not follow-up on treatment;
• provide crisis intervention and follow-up;
• monitor member entitlements, insurance, and other benefits to ensure they remain active and in place;
• advocate for members to resolve crises;
• collaborate with other professionals to evaluate members’ medical or behavioral health condition and to assess member needs;
• responsible for emergency on call for 2 to 3 weeks out of the year;
• Manage wrap around funds, metro cards and checks for member purchases, including obtaining the necessary approvals for all purchases in keeping with the member’s goals.

QUALIFICATIONS

EDUCATION AND EXPERIENCE

• High School Diploma and CASAC plus four (4) years of related human services experience in providing direct services to individuals with chronic health and/or behavioral health disorders. Or
• Associate Degree in one of the following fields: Human Services, Psychology, Rehabilitation, Nursing, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Health, Physical or Recreational therapy. Plus three (3) years of related human services experience in providing direct services to individuals with chronic health and/or behavioral health disorders. Or
• Bachelor’s Degree in one of the following fields: Social Work, Psychology, Education, Rehabilitation, Nursing, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Hearing, Physical or Recreational therapy. Plus two (2) years of related human services experience in providing direct services to individuals with chronic health and/or behavioral health disorders. Or
• Master’s Degree in one of the following fields: Social Work, Psychology, Education, Rehabilitation, Nursing, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Health, Physical or Recreational therapy. Plus one (1) year of related human services experience in providing direct services to individuals with chronic health and/or
• In rare circumstances, staff may have unique education and/or experience to adequately serve the HH+ SMI population but do not meet the qualifications outlined above and the agency may submit a waiver and encourage those to still apply.*