Care Coordinator DOH - Full-time; 4401-204-N

For over 125 years, Catholic Charities Brooklyn and Queens has been providing quality social services to the neighborhoods of Brooklyn and Queens, and currently offers 160-plus programs and services for children, youth, adults, seniors, and those struggling with mental illness. The Care Coordination program offers services to adults and children ages 6 to 18 enrolled in the Coordinated Behavioral Care (CBC) Health Home Program with a history of serious mental illness and/or multiple hospitalizations. The goal is to connect clients and families to various community resources identified as beneficial to the clients’ overall holistic well-being in order to reduce emergency room visits, inpatient stays and criminal justice involvement.

STATEMENT OF THE JOB

Under the direct supervision of the Team Supervisor, the Care Coordinator has overall day-to-day responsibility and accountability for coordinating all aspects of an assigned health home member’s care with complex medical and/or psychiatric co-morbid conditions and for facilitating their access to the full range of medical and psychosocial services in an efficient and effective manner. Duties of Care Coordinator focus on integration and coordination of physical health and mental needs. The Care Coordinator has to become an active participant in all phases of care transition to assure that enrollees received all required mental and medical follow up care and services and re-engagement of patients who have become lost to care. The Care Coordinator 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

Demonstrates commitment to the vision of Health Home and strategic priorities to ensure their achievement. Accountable for engaging and retaining 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 care. In 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 individual’s 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. 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 fashion. Outreach 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). Aids the health home members in identifying the primary care physician and multidisciplinary teams of medical, mental health, chemical dependency treatment providers, social workers, nurse’s 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 information. Refer health home members to peer supports and coordinate peer supports, support groups, and self-care programs to increase client’s and caregivers knowledge about the individual’s 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 member’s 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 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 member’s health and community services. 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 every 6 month direct s or as needed (as per SOMH CAIRS requirements). 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 care. Reports 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 issue. Cooperates with any and all investigations conducted by the Agency, funding sources and any other authorized agencies/entities. SPECIFICATIONS FOR EDUCATION/CERTIFICATIONS/LICENSES Bachelor’s 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 field.

SPECIFICATIONS FOR EXPERIENCE AND TRAINING

The position requires a combination of skills in the areas of crisis intervention, time management, psychosocial rehabilitation skills Ability 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 essential. Excellent computer skills are necessary. Knowledge of the community medical resources and their financial requirements. Good oral and written communication skills. Fluency in second language preferred

SPECIFICATIONS FOR PHYSICAL REQUIREMENTS

Ability 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 visits. Able to stretch and bend to retrieve files. Able to operate a computer keyboard, mouse, & office equipment. Able to sit and work on the computer for long periods of time. Able to travel to multiple locations as needed.

BENEFITS

We offer competitive salary and excellent benefits including: Generous time off (Vacation/ Personal Days/ Sick Days/ Paid Holidays annually) Medical, Dental Vision Retirement Savings with Agency Match Transit Flexible Spending Account Life insurance Public Loan Forgiveness Qualified Employer Training Series and other additional voluntary benefits. For more information on our organization, please visit our website at:

EOE/AA.

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