Nurse (Health Care)

Position: Health Navigator/Care Coordinator, Care Management Services (CMS)
Function: Responsible for the assessment and engagement of clients around health and wellness and the development of a comprehensive care plan.
Reports to : Director, Care Management Services
Schedule: Mondays-Fridays (9:00am-5:00pm)
Develops rapport with clients in order to engage them in improving their health and wellness.
Administers standardized health and psychosocial risk screenings according to Health Home protocols and timeframes.
Utilizes health screenings to identify interventions and develop a comprehensive care plan
Collaborates with members of the care team to identify needs and develop a plan to help client achieve optimal health outcomes.
Implements tasks outlined on the care plan and ensures follow up and continuity of care between client interactions.
Regularly reviews and updates the care plan to correspond with services being provided.
Documents all interventions and attempted contacts in the EHR in accordance with program standards.
Works in collaboration with care providers to address Gaps in Care
Works with family members and other collaterals of the clients choice to facilitate planning and delivery of care
Provides comprehensive transitional care following hospitalization events in accordance with ACMH Critical Time Intervention (CTI) Protocols.
Reviews new information and complex cases with PCP and multidisciplinary team and incorporates recommendations into the care plan.
Facilitates care delivery by scheduling appointments, obtaining necessary information, and arranging transportation.
Identifies community resources and makes referrals as needed.
Attends in-service training as requested
degree in social services or related field and two years of experience providing direct service in the human service field or nursing or CM/Service Coordination. Bilingual English/Spanish preferred.
ACMH is committed to the mental and physical wellbeing of vulnerable New Yorkers and is a leader in the provision of outreach and engagement, care management, rehabilitation, crisis support, and supportive housing. ACMH is committed to becoming an anti-racist organization and seeks to promote actionable change to create an intentional culture of equity at individual, interpersonal and institutional levels.
For more information, visit our website:
ACMH is an equal opportunity employer and does not discriminate in employment decisions based on race, color, creed, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, mental or physical disability, marital status, veteran status or citizenship status.