Children's Health Home Care Coordinator

Postgraduate-Center-For-Mental-Heal; New York (NY); On-site; USD 42,000 - 65,000; Full time

Job summary

Postgraduate-Center-For-Mental-Heal is seeking a Care Coordinator to address member needs, update care plans, and conduct outreach between visits. You will coordinate care for NYC Medicaid beneficiaries with chronic health and/or behavioral health disorders using a Health Home model.

You will engage with primary and specialty care physicians, mental health providers, families, and community resources to improve wellness and reduce ER visits.

Qualifications

• High School Diploma and CASAC plus four years of related human services experience.
• Associate Degree in one of the fields listed plus three years of related experience.
• Bachelor’s Degree in one of the fields listed plus two years of related experience.
• Master’s Degree in one of the fields listed plus one year of related experience.
• In rare cases, staff may have unique education/experience to warrant a waiver for HH+ SMI population.

Responsibilities

• Coordinate care for a caseload of 40–50 members.
• Maintain monthly contact with all caseload members.
• Conduct engagement activities (face-to-face, mail, electronic, phone).
• Communicate with primary and specialty care providers, family, and other staff on behalf of members.
• Maintain documents, records, statistics, and reports per policy.
• Conduct initial and periodic needs assessments and identify barriers.
• Assist with care plan development and communication to suitable health literacy levels.
• Record client progress against measurable care plan goals.
• Help members access healthcare and social systems, including transportation.
• Identify community resources and manage referrals and follow-up.
• Coordinate access to individual and family supports and resources.
• Assist with daily routines related to healthcare and identify barriers.
• Conduct outreach to support continuity of care and re-engagement.
• Provide crisis intervention and follow-up.
• Monitor entitlements and benefits to ensure active coverage.
• Advocate to resolve crises and collaborate with other professionals on needs.
• Handle emergency on-call duties for 2–3 weeks per year.
• Manage wrap-around funds, metro cards, and checks with required approvals.

Education

High School Diploma and CASAC

Associate Degree in Human Services/Psychology/Rehabilitation/Nursing/Counseling/Community Mental Health/Sociology

Bachelor’s Degree in Social Work/Psychology/Education/Rehabilitation/Nursing/Counseling/Community Mental Health

Master’s Degree in Social Work/Psychology/Education/Rehabilitation/Nursing/Counseling/Community Mental Health

Waiver consideration for HH+ SMI population (rare)

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:Responsibilities include but are not limited to the following:• 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.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.*