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EVERGREEN HEALTH
The Clinical Care Coordinator provides care coordination for clients with a diagnosis of Serious Mental Illness (SMI), substance use disorder, other chronic health conditions and patients enrolled in Health and Recovery Plans (HARP). The Clinical Care Coordinator assesses patients using the HCBS Eligibility Assessment, communicating with MCOs regarding Plans of Care, and coordinating referrals to HCBS providers under HARP. Services include the activities of case management, inclusive of 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). Additional duties may include crisis intervention and lethality assessment.
As part of the Essential Function for this role, the Clinical Care Coordinator:
Completes the Eligibility Assessment with patients enrolled in Health and Recovery Plans (HARP)
Enters data collected from the Eligibility Assessment into the NYS Health Commerce System; Submits the results of both Assessments to MCOs for approval and service determination
Completes the HARP Plan of Care with HARP enrolled patients, communicates with MCOs and Home and Community Based Providers (HCBS) to ensure referral and linkage to services outlined in the Plan of Care.
Consults with primary care physician and/or any specialists involved in the treatment plan; Coordinates with treating clinicians to ensure that services are provided and to ensure changes in treatment or medical conditions are addressed
Prepares client crisis intervention plan, as needed
Coordinates with service providers and health plans as appropriate to secure necessary care, shares crisis intervention and emergency information
Links/refers client to needed services to support care plan/treatment goals including medical/behavioral health care, patient education, and self-help/recovery and self- management; Advocates for services and assist with scheduling of needed services
Monitors/supports/accompanies client to scheduled medical appointments
Follows up with hospitals/ER upon notification of a clients admission and/or discharge to/from an ER, hospital/residential/rehabilitative setting
Participates in discharge care planning from an ER, hospital/residential/rehabilitative setting to ensure a safe transition/discharge that ensures care needs are in place
Qualified Candidate will have a Masters of Social Work, Mental Health Counseling, or other related field with one (1) year of qualifying post-graduate experience. Qualifying experience means post-graduate experience providing direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or linking individuals with Serious Mental Illness, developmental disabilities, or substance use disorders to a broad range of services essential to successful living in a community setting. Must possess a valid NYS Drivers License and an insured, dependable car to use for client service activities, including transporting clients when necessary. Sensitivity to HIV/AIDS and lifestyle issues is essential.
Job Type: Full-time
Required education: Masters (plus 1 year experience) (LMSW, LMHC, LCSW preferred); OR Bachelors (plus 2 years experience) (CASAC preferred)
Required experience: Working directly with people living with Severe Mental Illness (SMI) and Substance Use Disorder (SUD)
Additional requirements: Valid NYS drivers license and insured, dependable car
