Health Home/HH Plus Care Coordinator

Postgraduate-Center-For-Mental-Heal; New York (NY); On-site; USD 55,000 - 75,000; Full time

Job summary

Postgraduate-Center-For-Mental-Heal is seeking a Health Home/HH+ Care Coordinator to deliver intensive, person-centered care management for adults with complex behavioral health, medical, housing, and social-service needs across Manhattan, the Bronx, and Brooklyn.

You will manage a caseload, conduct field visits, complete plans of care, coordinate transitions from hospital to community settings, provide outreach and crisis intervention, and document timely progress notes and EHR entries to

Qualifications

• Master's degree in a qualifying field with at least one year of qualifying experience, or a Bachelor's with at least two years.
• CASAC with at least two years of qualifying experience, or a Bachelor's or higher with at least three years in relevant roles.
• Qualifying fields include social work, psychology, nursing, rehabilitation, education, or related human services.

Responsibilities

• Manage an assigned caseload of up to 20 members, applying HH/HH+ protocols.
• Provide core Health Home services and HH+ enhanced services.
• Conduct frequent field-based visits across Manhattan, the Bronx, and Brooklyn.
• Develop and update person-centered Plans of Care addressing multiple needs.
• Coordinate care with medical, behavioral health, housing, and social providers.
• Coordinate transitions of care from hospitals to community settings; post-discharge follow-up.
• Provide outreach, engagement, and re-engagement for missed appointments.
• Assess risk, document progress, and escalate to clinical leadership as needed.
• Complete required records, assessments, and timely documentation; participate in supervision and quality-improvement activities.

Skills

Field-based care coordination

Crisis intervention

Documentation & notes

Interdisciplinary collaboration

Education

Master's degree in a qualifying field

Bachelor's degree in a qualifying field

CASAC certification

Additional qualifying experience in health services

Job description

JOB SCOPE:As a member of the Care Coordination team and under the supervision of the Program Supervisor/Team Leader, the Health Home / Health Home Plus (HH+) Care Coordinator provides comprehensive, person-centered and intensive care management to adults with complex behavioral health, medical, substance use, housing, and social-service needs. The position serves individuals enrolled in Medicaid Health Home, including members who meet HH+ criteria such as high-need Serious Mental Illness (SMI) and Assisted Outpatient Treatment (AOT), and may also serve assigned non-Medicaid care coordination cases. The Care Coordinator maintains a total caseload of up to 20 individuals, adjusted as appropriate for acuity, HH+ requirements, program needs, and applicable regulatory standards.This is a field-intensive position serving Manhattan, the Bronx, and Brooklyn. The Care Coordinator meets members where they are - including homes, shelters, hospitals, psychiatric inpatient units, detoxification/rehabilitation programs, outpatient clinics, and community agencies - and plays a central role in transitions of care, engagement, service coordination, advocacy, crisis prevention, and continuity of treatment. The goal is to promote stability, wellness self-management, community tenure, and successful connection to medical, behavioral health, housing, benefits, and social supports while reducing avoidable emergency department use and hospitalization.ESSENTIAL FUNCTIONS:· Manage an assigned caseload of up to 20 HH, HH+, and/or non-Medicaid care coordination members, providing services according to member acuity, risk, eligibility, individualized needs, and applicable program requirements.· Provide required Health Home core services and HH+ enhanced services, including comprehensive care management, care coordination and health promotion, transitional care, member/family support, and referrals to community and social supports. Ensure required service intensity and face-to-face contacts are completed for HH+ and AOT members.· Conduct frequent field-based visits throughout Manhattan, the Bronx, and Brooklyn, including member homes, shelters, hospitals, inpatient and outpatient treatment settings, and community agencies.· Complete comprehensive assessments and develop, implement, monitor, and update person-centered Plans of Care addressing behavioral health, medical, substance use, housing, benefits, social, functional, safety, and other identified needs, strengths, preferences, and goals.· Coordinate care and maintain effective communication with medical, behavioral health, substance use, hospital, housing, managed care, family/support, and community providers, including interdisciplinary case conferences and follow-up on referrals and treatment recommendations.· Coordinate transitions of care from hospitals, emergency departments, psychiatric inpatient units, detox/rehabilitation programs, and other institutional settings; complete timely post-discharge follow-up to support medication access, appointments, transportation, housing, benefits, and continuity of treatment.· Provide assertive outreach, engagement, and re-engagement for members who miss appointments, disengage from treatment, cannot be located, or are at risk for loss of continuity of care, including required diligent-search activities.· Assess and monitor member risk, functioning, and changes in condition; provide crisis intervention, safety planning, advocacy, and timely escalation/coordination with clinical, supervisory, emergency, and community resources as indicated.· Assist members in accessing and maintaining needed healthcare, behavioral health treatment, housing, benefits/entitlements, transportation, peer supports, rehabilitation, vocational/educational, legal, and other community resources, including scheduling, referrals, follow-up, and accompaniment when appropriate.· For members subject to AOT, coordinate with assigned AOT/LGU staff; comply with Kendra's Law and the individual's court order; and complete required AOT/CAIRS, status, and significant-event reporting.· Complete all required assessments, screenings, Plans of Care, progress notes, encounter/billing documentation, transition documentation, reports, and other records accurately and within established regulatory and agency timeframes. Progress notes must be completed within 24 hours of each reportable service activity.· Complete and submit required End of Day (EOD) reports each workday, accurately reflecting member contacts, outreach attempts, field activities, documentation status, scheduled activities, and other information required by program leadership.· Maintain accurate, organized, and audit-ready records in the agency EHR and required State/Lead Health Home systems, and ensure documentation supports services provided and applicable billing requirements.· Participate in supervision, case review, team meetings, utilization/billing review, quality-improvement activities, required training, and on-call/after-hours coverage when assigned.· Manage approved member-support resources in accordance with agency policies and required approvals and perform other duties consistent with program goals as assigned by authorized program leadership.EDUCATION AND EXPERIENCE:Minimum HH+ SMI staff qualifications (one of the following):· Master's degree in a qualifying field and at least one (1) year of qualifying experience; OR· Bachelor's degree in a qualifying field and at least two (2) years of qualifying experience; OR· Credentialed Alcoholism and Substance Abuse Counselor (CASAC) with at least two (2) years of qualifying experience; OR· Bachelor's degree or higher in any field with at least three (3) years of qualifying experience, or at least two (2) years of experience as a Health Home care manager serving the SMI or SED population.*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.*Qualifying fields include: social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation/recreational therapy, counseling, community mental health, child and family studies, sociology, speech and hearing, or another human services field.Qualifying experience includes: providing direct services to individuals with Serious Mental Illness, developmental disabilities, substance use disorders/alcoholism, and/or children with SED; or linking such individuals to a broad range of medical, psychiatric, social, educational, legal, housing, financial, and other services essential to successful community living.Preferred: Experience with Health Home/HH+, AOT, transitions of care, hospital discharge planning, community outreach, supportive housing/homeless services, co-occurring disorders, and NYC behavioral health systems. Master's degree and/or professional licensure is a plus.