Care Coordinator

Care CoordinatorAt 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. As a result, Fountain House has created a comprehensive Community System of Care. This includes Clubhouses in Manhattan, the Bronx, Hollywood, California and Care Management, Home and Community-Based Services and a large housing program 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.Fountain House's Care Management is a Health Home Care Management agency serving individuals living with serious and persistent mental illness. We are the team helping Medicaid recipients to work on person-centered goals and care management to ensure all their medical and psychiatric needs are being met in an efficient and effective manner.The Care Coordinator is responsible for coordinating health care and ensuring all needs are being met for members in the community who have chronic medical and/or mental health conditions to ensure positive health outcomes, decreased redundancy of care, decreased hospitalizations and secured and sustained social determinants of health such as benefits, food security and housing. The Care Coordinator assists clients in overcoming barriers to quality health care, striving to improve overall health outcomes, reduce avoidable Emergency Room (ER) usage and inpatient hospitalizations. The Care Coordinator is responsible to connect members to appropriate medical services, coordinate care with members' providers and supports, support clients to make well informed choices regarding treatment and provide education & empowerment. The position involves telephonic care coordination, on-site service provision as well as visiting members in the community. Care Coordinators are also responsible for conducting required assessments for health home enrollment and ongoing services.Care Coordinators at Fountain House will embody the values of the clubhouse model, demonstrating what we call our HERO characteristics: fierce optimism, professional curiosity, and a deeply communitarian approach to partnerships, leadership, and engagement.Onsite in Hell's Kitchen$30.58 per hourRequirementsEssential Duties and ResponsibilitiesOutreachDetermine 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 DocumentationMaintain 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 verificationDocument each and every service provided in progress notes entered no later than 48 hours after the encounterConduct 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 thereafterConduct initial and subsequent periodic needs assessments for care plans at initial enrollment meeting and every 6 monthsConduct comprehensive assessments within 60 days and annually thereafterComplete 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 webinarsMember SupportsUse resources or insurance databases to connect members to quality medical and behavioral health providers and specialistsConnect members to supports for education, employment, legal, food insecurities, and other community supportsApply for and/or maintain benefits such as Medicaid, Food Stamps (SNAP), Social Security, and Social Security DisabilitySecure 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 appropriateConduct case conferences with member, their service providers, and any consented supportsAccompany and support members to and during appointments when follow-up and advocacy is necessary for successAssist with transitional care during and after hospitalizations, including but not limited to responding to hospitalization alerts within 48 hours, case conference with hospital and service providers, escort to and from the hospital and 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 careAssess safety and conduct safety planning as neededAssist members in improving activities of daily living and goal setting, such as budgeting, hygiene, medication compliance, nutrition supportAssist members in accessing transportation, including obtaining half-fare cards, applying for Medicaid transportation (MAS) and ACCESS-A-RIDEImprove health literacy and provide psychoeducation for health conditionsAssist members in reading and understanding health care materialsConnect individuals to long term care services, such as managed long term care plans and home health aide servicesAssist members in managing chronic health conditionsCollaborate with support team including consented family membersOperate using social practice and relationship building within the care management modelRequired Knowledge, Skills, and AbilitiesExcellent verbal and written communication skills, including ability to effectively communicate with internal and external care teamsExcellent interpersonal skills and the ability to engage members effectivelyExcellent 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 servicesAbility to work independently and to conduct assignments to completion within parameters of instructions given, prescribed routines, and standard accepted practicesRequired and Preferred Education, Experience, and CredentialsBachelor's Degree required.Bilingual, Spanish speaking is a plus.3 years of experience in the mental health field or Health Home Care Management preferredCommunity Health Work certification preferredPhysical RequirementsTo 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.