Care Coordinator

OUR VISION

To continue as an eminent healthcare provider on Long Island, dedicating ourselves to providing exceptional health care for all our patients and to transform both the lives of the individual, and the community, for the better, one person at a time.

OUR MISSION

To provide access to equitable, optimal healthcare by improving the overall wellness of all individuals in our communities and delivering high quality comprehensive patient centered care.

OUR VALUE PROPOSITION

To provide whole person care that will ensure that all patients have access to primary, specialty and social health care to achieve and maintain optimal wellness at a transparent and affordable cost.

JOB TITLE: Care Coordinator

REPORTS TO: Director of Care Coordination

The following statements reflect the general duties, responsibilities and competencies considered necessary to perform the essential functions of the job and should not be considered as a detailed description of all the work requirements of this position.

POSITION SUMMARY:

The Care Coordinator functions as a member of an interdisciplinary team to provide care coordination to a caseload of severely mentally ill adults with multiple medical comorbidities and/or co occurring substance abuse disorders and/or medically ill individuals. Advocates for and supports the client, engages with community agencies/health care providers and others on his behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations. Provides clinical support to the Team by providing consultation, education, information around psychosocial and/or substance abuse conditions, interventions, resources to maintain focus on outcomes and best practices.

RESPONSIBILITIES:

• Conducts initial and ongoing assessments of assigned clients to document strengths, needs, goals and resources.

• Participates in the development/documentation /review and update of client centered comprehensive, integrated, interdisciplinary care plan in consultation with Care Manager and other team members to ensure focus on desired outcomes.

• Maintains effective communications with clients, primary care physicians, substance abuse and mental healthcare providers, family, collateral resources and other Agency staff on behalf of clients.

• Maintains documents, records, statistics, and other related reports in an organized, timely and accurate manner as per policy and procedure.

• Coordinates care planning with other providers of services/ resources to ensure goal directed, collaborative care, including care transitions.

• Works as part of a Care Coordination team; attends and participates in team meetings to provide input/feedback around psychosocial conditions/co morbidities to review client status, update plans and goals, review outcomes to further program goals.

• Acts as a resource/consultant to all team members on psychosocial and/or substance abuse issues and resources.

• Provides telephonic as well as face to face outreach, engagement and service planning in the field.

• Acts as a linkage to community services including medical, behavioral, residential, entitlement and any other needed services per interdisciplinary care plan.

• Monitors overall service delivery to clients to ensure coordination and continuity; advocates with service providers/resources as needed.

• Provides crisis intervention and follow-up.

• May be assigned other tasks and duties reasonably related to the job responsibilities.

QUALIFICATIONS:

• High School diploma/GED with additional training in human service delivery required.

• Bachelor's Degree or Master's Degree in one of the following fields preferred: Social Work, Psychology, Education, Rehabilitation, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Hearing, Physical or Recreational therapy.

• For H.S. Diploma/GED level candidates, four (4) years of related human services experience required in providing direct services to mentally, developmentally or other disabled clients in order to link them to a broad range of services essential to successfully living in the community.

• For B.A. level candidates, two (2) years of related human services experience required in providing direct services to mentally, developmentally or other disabled clients in order to link them to a broad range of services essential to successfully living in the community.

• For M.A. level candidates, one (1) years of related human services experience required in providing direct services to mentally, developmentally or other disabled clients in order to link them to a broad range of services essential to successfully living in the community.

• Working knowledge of computer software and electronic health record systems.

• Demonstrated competency in written, verbal and computational skills to present and document records in accordance with program standards.

• Experienced in and demonstrated comprehensive understanding and working knowledge of the interdisciplinary planning process and the developmental treatment model.

• Knowledge of Medicaid, Social Security and other entitlements preferred.

• Excellent interpersonal skills required.

• Bilingual in Spanish

• You must have the ability and willingness to regularly travel, in some instances with clients in Agency vehicles, to many locations using various modes of reliable and safe transportation. If working in Nassau or Suffolk Counties, a valid Tri-state (New York, New Jersey or Connecticut) driver's license is required.

SALARY: Commensurate with experience

MORE INFORMATION: This is a non-exempt position.