The Care Coordinator applies 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 & Family Support and Referral to Community & Social/Support Services). The Care Coordinator will be responsible for the following outcomes: Reduce utilization associated with avoidable and preventable inpatient stays, reduce utilization associated with avoidable emergency room visits, improve outcomes for persons with mental health illness and/or substance use disorders; and improve disease-related care for chronic conditions.
As part of the Essential Functions for this role, the Care Coordinator:
Completes a comprehensive health assessment/reassessment inclusive of medical/behavioral/rehabilitative and long term care and social service needs
Completes/revises an individualized patient-centered plan or care with the patient to identify patient's needs/goals, and includes family members and other social supports as appropriate
Consults with multidisciplinary team on client's care plan/needs/goals
Conducts outreach and engagement activities to assess on-going emerging needs and to promote continuity of care and improved health outcomes
Consults with primary care physician and/or any specialists involved in the treatment plan
Prepares client crisis intervention plan
Coordinates with service providers and health plans as appropriate to secure necessary care, share crisis intervention and emergency information
Links individuals with Serious Mental Illness (SMI), developmental disabilities, or substance use disorders (SUD) to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services)
Qualified Candidate will have a Bachelor's degree in health, human or education services and one year of qualifying* experience or Associate's degree in health, human or education services and two (2) years of qualifying* experience. Qualifying* experience equals professional case management or care coordination experience with the following populations: persons with a chronic illness, and/or persons with a history of mental illness, homelessness, or chemical dependence. Candidate must have a valid NYS Driver's License and an insured, dependable car.
Job Type: Full-time
Required education: Bachelor's (plus 1 year experience); Associates (plus 2 years experience)
Required experience: Care Coordination/Case Management; Working with clients experiencing chronic illness, homelessness, mental illness and/or chemical dependence
Additional requirements: Must have dependable, insured vehicle and NYS Driver's License