Care Coordinator II

Regular Full-Time

Buffalo, NY, US

Salary Range: $20.08 To $25.60 Hourly

Agency Profile: Spectrum Health & Human Services respectfully partners with adults, children, and families as they recover from behavioral, emotional, mental health and/or substance related disorders by offering individualized and meaningful opportunities of hope, empowerment and support to achieve self-defined improvements in their quality of life.

Full-time: 1298 Main Street, Buffalo, NY

SUMMARY OF POSITION FUNCTION:

The Care Coordinator II will apply the essential activities of case management which include assessment, planning, coordination, monitoring and evaluation with the core components (Comprehensive Case Management, Care Coordination & Health Promotion, Comprehensive Transitional Care, Patient and Family Support and Referral to Community & Social/Support Services). The Care Coordinator will be responsible for the following outcomes: to reduce utilization associated with avoidable and preventable inpatient stays, to reduce utilization associated with avoidable emergency room visits, to improve outcomes for person with mental health illness and/or substance use disorders and to improve disease-related care for chronic conditions.

MAJOR DUTIES AND RESPONSIBILITIES:

• Complete a comprehensive health assessment/reassessment inclusive of medical/behavioral/rehabilitative and long term care and social service needs.

• Complete/revise an individualized patient centered plan or care with the patient to identify patient’s needs/goals, and include family members and other social supports as appropriate.

• Consult with multidisciplinary team on client’s care plan/needs/goals.

• Conduct outreach and engagement activities to assess on-going emerging needs and to promote continuity of care and improved health outcomes.

• Consult with primary care physician and/or any specialists involved in the treatment plan.

• Prepare client crisis intervention plan.

• Coordinate with service providers and health plans as appropriate to secure necessary care, share crisis intervention and emergency information.

• Link/refer client to needed services to support care plan/treatment goals, including medical/behavioral health care; patient education, and self help/recovery, and self management.

• Conduct case conferences with an interdisciplinary team to monitor and evaluate client status.

• Advocate for services and assist with scheduling of needed services.

• Coordinate with treating clinicians to assure that services are provided and to assure changes in treatment or medical conditions are addressed.

• Monitor/support/accompany the client to scheduled medical appointments.

• Follow up with hospitals/ER upon notification of a client’s admission and/or discharge to/from an ER, hospital/residential/rehabilitative setting.

• Facilitate discharge planning from an ER, hospital/residential/rehabilitative setting to ensure a safe transition/discharge that care needs are in place.

• Notify/consult with treating clinicians, schedule follow up appointments, and assist with medication reconciliation.

• Link client with community supports to ensure that needed services are provided.

• Follow-up post discharge with client/family to ensure client care plan needs/goals are met.

• Develop/review/revise the individual’s plan of care with the client/family

• Consult with client/family/caretaker on advanced directives and educate on client rights and health issues, as needed

• Meet with client and family, inviting any other providers to facilitate needed interpretation services.

• Refer client/family to peer supports, support groups, social services, entitlement programs as needed.

• Identify resources and link client with community supports as needed

• Collaborate/coordinate with community base providers to support effective utilization of services based on client/family need.

• Maintains complete, current and accurate member files which comply with The Health Home Standards. Documents all member related activity in a progress note by the conclusion of the next business day.

• Other duties as requested.

SKILLS/COMPETENCIES:

• Effective verbal and communication skills

• Ability to teach and influence others

• Demonstrated ability to work effectively in a team environment.

• Demonstrated effective interpersonal relationship and customer services skills

• Good organizational and time management skills

• Ability to work effectively with people from diverse cultures and socioeconomic conditions.

• Actively listens to others to understand their perspective and ensure understanding regardless of barriers.

• Critical thinking ability

• Ability to handle protected health information (PHI) in a manner consistent with The Health Insurance Portability and Accountability Act of 1996.

• Knowledge of computerized systems.

• Knowledge of local and surrounding area resources

EDUCATION REQUIREMENTS:

• Bachelor or master’s degree in a Human Service field and at least three years’ experience working in the human service field OR Must have three years’ experience at Spectrum as a Care Coordinator I with positive job performance.

EXPERIENCE:

• • “Qualifying Experience” means verifiable full or part-time experience in care coordination with the following populations: person with a chronic illness, and/or persons with a history of mental illness

• Must possess a valid Driver’s License with a satisfactory driving record, and possess a personal vehicle for job requirement

COMPENSATION: $20.08/hr- $25.60/hr