Non-Medicaid Care Coordinator

Postgraduate Center for Mental Health; New York (NY); On-site; USD 52,000 - 68,000; Full time

Job summary

Postgraduate Center for Mental Health seeks a Care Coordinator to join its Care Coordination team. Under supervision, you will address member needs, provide care plan updates, and conduct outreach between visits.

You will coordinate care for 40-50 members and engage with healthcare providers and families to support comprehensive care. You will perform needs assessments, help tailor communications to health literacy levels, and assist with accessing healthcare and social services, including

Qualifications

• High School Diploma and CASAC required.
• Associate Degree in relevant field plus three years of related human services experience.
• Bachelor’s Degree in relevant field plus two years of related human services experience.
• Master’s Degree in relevant field plus one year of related human services experience.

Responsibilities

• Coordinate care for a caseload of 40-50 members.
• Maintain monthly contact with all caseload members, with increased contact for new and high-risk members.
• Engage members post-handover from Outreach Team through face-to-face, mail, electronic, and phone contact.
• Communicate with primary and specialty care physicians, mental health providers, family, and staff on behalf of members.
• Maintain organized records, statistics, and reports as per policy and procedure.
• Conduct initial and periodic needs assessments, considering barriers, assets, language, literacy, and culture.
• Assist in developing and executing member care plans and communicating at appropriate health-literacy levels.
• Record client progress against measurable goals in the care plan.
• Assist members in accessing healthcare and social systems, arranging transportation, scheduling, and accompanying to appointments.
• Identify community resources and coordinate referrals, access, engagement, follow-up, and services coordination.
• Coordinate access to individual and family supports and resources.
• Assist with daily routines related to healthcare and leverage member strengths to overcome barriers.
• Support outreach and engagement activities to ensure continuity of care and re-engage members who miss appointments.
• Provide crisis intervention and follow-up.
• Monitor member entitlements, insurance, and benefits to ensure active coverage.
• Advocate for members to resolve crises.
• Collaborate with professionals to evaluate medical/behavioral health needs.
• On-call emergency support 2-3 weeks per year.
• Manage wrap-around funds, metro cards, and checks with approvals aligned to member goals.

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 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

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

• 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