Care Coordinator - PCMH Health Homes
Care Coordinator - PCMH Health Homes
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Salary Not Disclosed
1 Vacancy
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 members behalf to ensure access to services needed to increase wellness selfmanagement 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 4050 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 facetoface 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 of members 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 communitybased resources and actively manage appropriate referrals access engagement followup 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 reengaging members in care if they miss appointments and/or do not followup on treatment;
- provide crisis intervention and followup;
- 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 members goals.
KNOWLEDGE:
- Knowledge of Health Home Care Coordination
- Knowledge of Medicaid Social Security and other entitlements.
- Basic knowledge of HIV/AIDS Substance Abuse and Mental Health.
- Knowledge of community resources available to the population served.
- Computer literacy; including Office programs and EHRs.
SKILLS AND ABILITIES:
- Excellent oral and written communication skills
- Ability to multitask.
- Well organized with attention to detail
- Ability to effectively manage time
- Strong engagement and advocacy skills.
- Excellent interpersonal skills.
- Ability and willingness to travel regularly in some instances with clients to many locations using various modes of reliable and safe transportation.
- Ability to work with multiple electronic medical records.
- Ability to use good judgment in seeking supervisory assistance when appropriate.
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
- Bachelors 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
- Masters 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
Required Experience:
IC
Employment Type
Full-Time
