Care SpecialistN

STATEMENT OF THE JOBUnder the direct supervision of the HH Team Supervisor the Care Specialist has overall day-to-day responsibility and accountability for coordinating all aspects of care for assigned health home serving children members with complex medical and/or psychiatric co-morbid conditions and for facilitating their access to the full range of medical behavioral health substance use social and psychosocial services in the community in an efficient and effective manner. Duties of the Care Specialist focus on integration and coordination of physical health mental health and social service needs. The Care Specialist has to become an active participant in all phases of care transition to assure that members receive all required mental and medical follow up care and services and must also take action around re-engagement of members who have become lost to Care Specialist electronically monitors and tracks data regarding health home member and alerts all members of the Care Team when follow-up is required. DUTIES AND RESPONSIBILITIES ESSENTIAL FUNCTIONS:Demonstrates commitment to the vision of Health Home and strategic priorities to ensure their achievement. Accountable for engaging and retaining Queens health home members in care coordinating and arranging for the continuous provision of services supporting adherence to treatment recommendations monitoring and evaluating their needs including prevention wellness medical specialist and behavioral health treatment care transitions and social and community services where appropriate through the creation of an individual plan of collaboration with the health home members their family and/or caregivers and other service providers develops manages and coordinates a comprehensive individualized person-centered care plan that coordinates and integrates the continuum of medical behavioral health services rehabilitative long term care and social service needs and clearly identifies the primary care physician/nurse practitioner specialists behavioral health care providers care manager and other providers directly involved in the individuals care. Ensures the availability of priority appointments for health home members to care services including physical psychiatric and substance abuse within their health home provider network to avoid unnecessary inappropriate utilization of emergency room and inpatient hospital services. Promotes evidence based wellness and prevention by linking health home members with resources for smoking cessation diabetes asthma hypertension self-help recovery resources and other medical services based on individual physical needs and preferences. Tracks and shares health home members information and care needs across providers by utilizing electronic databases and monitors outcomes and initiate changes in care as necessary to address health home members needs. Reassesses needs for Health Home services and reviews health home members historical or targeted clinical measurements (i.e. number of ER visits and inpatient psychiatric admissions). Identifies potential barriers to successful care and resolutions to those barriers. Completes contact notes incident reports and other required documentation and maintains accurate recordings in electronic case files in a requested timely CANS-NY training and examination to properly assess clients being servedChecks that health home members receive test results and tracks that patients follow up with medical directions. Prepares and follows-up on a list of health home members who need preventive or metabolic screening appointment via phone to health home members between visits (check on self-care medication fills treatment plan schedules visits tests/follow-up) Monitors that the health home member completes post-visit follow-up (fill prescriptions make appointments). Monthly Face to face visit with client/child as well as monthly follow up (telephonic or face to face) with various providers/collaterals (i.e. guidance counselors parents/guardians therapists ACS etc.)Aids the health home members in identifying the primary care physician and multidisciplinary teams of medical mental health chemical dependency treatment providers social workers nurses nutritionists/dieticians pharmacists outreach workers including peer specialists and other care providers to assure that enrollees receive needed medical behavioral and social services in accordance with a plan of care. Responsible for maintaining the security of all data files and employ approved methods of data encryption to prevent theft of personally identifiable Queens health home members to peer supports and coordinate peer supports support groups and self-care programs to increase clients and caregivers knowledge about the individuals diseases promote the health home members engagement and self-management capabilities and help the to improve adherence to their prescribed treatment order to allow them to make informed decisions. Assure timely and comprehensive transitional care from an inpatient facility (hospital rehabilitative psychiatric skilled nursing or treatment facility) to follow-up with post discharge interventions in order to prevent health home members avoidable readmission after discharge and to ensure proper and timely follow up care. Develops and maintains health home networks with primary medical and specialty practitioners and mental health providers substance abuse service providers community based organizations managed care plans emergency rooms hospitals and residential/rehabilitation settings community-based services to ensure coordinated and safe transition in care for its patients who require transfer to/from sites of care. Utilizes regional health information organizations (RHIOs) and other data systems to track and share health home members information and care needs across providers monitor their outcomes and initiate changes in care as necessary to provide the health home prompt notification of an individuals admission and/or discharge to/from an emergency room inpatient or residential/rehabilitation setting and address immediate needs in order to maximize optimum care and timely treatments services and referrals. Utilizes and electronically tracks all specialty medical behavioral and support service referrals made for health home members and ensures that the member follows up and receives all of the care they need. Tracks and arranges appointments educate health home members and coordinate all aspects of the members health and community services. Able to utilize technology conferencing tools including audio video and /or web deployed solutions and accountable for hand-held devices (I Phone Blackberry I Pad Tablets Laptops etc.).Makes sure that health home members entitlements insurance and benefits are in place. Provides interpreter services as required. Responsible for direct service provision of services to the consumer based on needs as established and documented in comprehensive assessments and service plans. This will be re-evaluated and adjusted in the care coordination platform every 6 months or as needed (per goal change or change in life event)Work schedule includes holiday coverage to accommodate the coverage needs of the program when required. 24 hours/seven days a week availability to provide information and emergency consultation services and provide escorts to health home members from ER hospital and other settings to alternative level of to Behavioral Health Services Administration and/or Agency Administration issues that may have a negative impact on the reputation of the Agency client and/or staff welfare or any corporate compliance with any and all investigations conducted by the Agency funding sources and any other authorized agencies/ DUTIES:Attends required in-service programs and trainings. Collaborate with program management in the identification of developing marketing in a timely fashion scheduled vacation and time off request from the Clinical Director to ensure continuous coverage of programs other related duties as requested or assigned by agency this is an evolving program additional responsibilities may be added and/or in committees as directed. SPECIFICATIONS FOR EDUCATION/CERTIFICATIONS/LICENSESBachelors degree in social work psychology or a related health/human services field with two (2) years of direct work with the target population. OR Degree/certification in Medical and Clinical Assistance or Health professional FOR EXPERIENCE AND TRAININGThe position requires a combination of skills in the areas of crisis intervention time management psychosocial rehabilitation skillsPosition requires CANS-NY certificationAbility in linking clients to a broad range of services essential to successfully living in a community setting (e.g. medical psychiatric social educational legal housing and financial services). Must have excellent communication skills. Cross-cultural competency outreach interviewing listening advocating linking negotiating engagement monitoring and clinical assessment skills are computer skills are of the community medical resources and their financial oral and written communication in second language preferredSPECIFICATIONS FOR PHYSICAL REQUIREMENTSAbility to work flexible hours and days including weekends/evenings/holidays according to needs of a 24/7 program. Regularly required to talk hear walk stand & sit. Able to lift up to 10 pounds. Able to climb stairs and make home to stretch and bend to retrieve to operate a computer keyboard mouse & office to read printed materials and computer screens. Able to to sit and work on the computer for long periods of to travel to multiple locations as needed.