Care Coordinator

POSITION SUMMARY

At Fountain House, we believe in the power of community to transform the lives of individuals with serious mental illness. Every day, thousands of members choose to come to Fountain House to contribute their talents, learn new skills, access opportunities, and form friendships. Members and staff operate successful employment, education, wellness programs and work as partners to perform all the functions that keep our community going. The Fountain House model has been replicated in more than 300 locations in 30 countries and 32 states and currently serves more than 100,000 people with mental illness worldwide. As originators of this approach, we provide leadership by constantly advancing the practice and by leading the conversation around mental health recovery. This has created a comprehensive Community System of Care that includes Clubhouses, Care Management, Home and Community‑Based Services, and housing programs ranging from 24‑hour supervised residences to scattered site supported apartments. We are committed to reducing social isolation, advocating for mental health policy change, and driving solutions that empower our members.

JOB DETAILS

Full‑time. On‑site in Hell’s Kitchen. Hourly rate $30.58 per hour.

CARE COORDINATOR RESPONSIBILITIES

Outreach Determine member eligibility through ePaces or Medicaid Analytics Performance Portal. Actively outreach eligible members through phone, Zoom, or in‑person meetings. Give educational presentations to a variety of Fountain House internal programs on care management services. Enroll 5 members per month until capacity of 50 members (HARP and non‑HARP) is reached. (*subject to change) Actively engage caseload in service provision in accordance with care plans. Enrollment, Health Information Technology, and Documentation Maintain documentation for enrollment including the DOH 5055, PSYCKES, Healthix, and withdrawal of consent. Enroll member into Relevant (Electronic Health Record, EHR). Maintain and update demographics in the electronic health records for each individual served quarterly, including upload of eligibility verification. Document each and every service provided in progress notes entered no later than 48 hours after the encounter. Conduct State regulated Eligibility Assessments for HARP members in UAS‑NY (New York State platform) and complete the Plan of Care for HCBS/CORES referrals within 60 days of enrollment and annually thereafter. Conduct initial and subsequent periodic needs assessments for care plans at initial enrollment meeting and every 6 months. Conduct comprehensive assessments within 60 days and annually thereafter. Complete extensive trainings for, including but not limited to, Relevant EHR, PSYCKES, Medicaid redesign, HCBS, CORES, Housing, Benefits, MAPP, UAS‑NY, and weekly Health Home value‑add webinars. Member Supports Use resources or insurance databases to connect members to quality medical and behavioral health providers and specialists. Connect members to supports for education, employment, legal, food insecurities, and other community supports. Apply for and/or maintain benefits such as Medicaid, Food Stamps (SNAP), Social Security, and Social Security Disability. Secure safe and affordable housing for low‑income, mental health (HRA 2010e, SPOA), and/or lottery apartments. Complete applications for one‑shot deals to ensure housing stability when appropriate. Conduct case conferences with member, their service providers, and any consented supports. Accompany and support members to and during appointments when follow‑up and advocacy is necessary for success. Assist with transitional care during and after hospitalizations, including responding to hospitalization alerts within 48 hours, case conference with hospital and service providers, escort to and from the hospital, follow‑up appointments, increased reach out and service provision after hospitalization, alert services providers to hospitalization, assist in helping transition back to prior level of care. Assess safety and conduct safety planning as needed. Assist members in improving activities of daily living and goal setting, such as budgeting, hygiene, medication compliance, nutrition support. Assist members in accessing transportation, including obtaining half‑fare cards, applying for Medicaid transportation (MAS), and ACCESS‑A‑RIDE. Improve health literacy and provide psychoeducation for health conditions. Assist members in reading and understanding health care materials. Connect individuals to long‑term care services, such as managed long‑term care plans and home health aide services. Assist members in managing chronic health conditions. Collaborate with support team including consented family members. Operate using social practice and relationship building within the care management model. Required Knowledge, Skills, And Abilities Excellent verbal and written communication skills, including ability to effectively communicate with internal and external care teams. Excellent interpersonal skills and the ability to engage members effectively. Excellent computer proficiency (MS Office – Word, Excel, and Outlook). Must be able to work under pressure and meet strict deadlines, while maintaining a positive attitude and providing high‑quality services. Ability to work independently and to conduct assignments to completion within parameters of instructions given, prescribed routines, and standard accepted practices. Required and Preferred Education, Experience, And Credentials Bachelor’s Degree required. Bilingual, Spanish speaking is a plus. 3 years of experience in the mental health field or Health Home Care Management preferred. Community Health Work certification preferred. Physical Requirements To perform this job successfully, an individual must be able to perform each essential duty and meet all physical requirements satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. #J-18808-Ljbffr Fountain House