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.Queens Care Coordination provides services to individuals with a history of serious mental illness and/or multiple hospitalizations. Services are tailored to meet individual needs. Services include treatment planning, connecting patients with necessary mental and physical health providers, medication education and management, assistance with benefits and entitlements, client empowerment, and Wellness Recovery Action Plan (WRAP) education.STATEMENT OF THE JOB:The Health Home Team Supervisor is a supervisor for the Medicaid – reimbursable population of clients belonging to one of our affiliated Health Homes. They oversee a Care Coordination team made up of BA/MA level Care Coordinators, Peer Coordinators and clinical workers (RNs and LCSWs). It is the Health Home Team Supervisor to focus the team’s activities on the integration and coordination of physical health and mental health needs internally and with affiliated agencies. * Oversee the proper follow up of an aggressive work plan of care by Care Coordinators and ensure it is accessible to the interdisciplinary team of providers for service integration, and for the utilization of health care services by health home members who have complex, chronic, high-cost conditions.* Direct and coordinate staff efforts for the promotion of evidence based wellness and prevention activities of the team for 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. * Regularly assesses the team’s caseload needs and goals and clearly identify reported progress in meeting goals by individual health home members as well as compliance with recommended treatments. Ensure fluidity of cases so that each member receives the level of care they require, when required.* Monitor Care Coordination team efforts to ensure health home member has needed services, which may include but are not limited to, acute, primary and preventive medical care, Home Health Care, Chemical Dependency Services, Behavioral Health Services, community social support services, housing, State and federal entitlements* Coordinate team activities to provide access to high-quality health care informed by evidence-based practice guidelines, transitional care- facilitating transfer from inpatient to other settings (such as participation in discharge planning; on –going medical care). * Lead team meeting to assure that communication is fostered between the dedicated Care Coordinators and Peers and treating clinicians to discuss as needed health home members’ care needs, conflicting treatments, change in condition, etc. which may necessitate treatment change (i.e., written orders and/or prescriptions). * Supervise the quality of Care Coordinators contacts with health home member - phone contacts, observes home visits and face to face meetings. Directly observe and review coordination of care for a higher risk cases. * Supervise reassessment 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). Report required information to manager to ensure timely submission of required reports.* Communicate with Staff Nurse, Consulting Psychiatrist and Director of Care Coordination regarding high risk cases, linkage to other Health Home providers, quality control, documentation of enrollee contact/interventions and program statistics.* Coordinate team’s activities 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 health home members receive needed medical, behavioral, and social services in accordance with a plan of care. * Ensure implementation of a continuous quality improvement plan for the team. Collects and reports on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level. * Provide supervision to team and health home members to ensure understanding lab and test results and other reports that impact on member’s physical and mental health. * Supervise peer supports and ensure support groups, and self-care programs are available to increase health home members’ and caregivers knowledge about the individual’s diseases, promote the health home member’s engagement and self-management capabilities, and help to improve adherence to prescribed treatment in order to allow them to make informed decisions * Evaluate staff performance and develop performance improvement plan, as needed.* Ensures that team meets initial Health Information Technology standards to fully implement a health home integration for the major clinical risk group categories of chronic behavioral and medical conditions * Review all specialty medical, behavioral, and support service referrals made for up health home members in the team’s caseload and ensure that they follow up and receive all of the care needed. * Utilizes regional health information organizations (RHIOs) and other data systems to track and share health home members’ information and care needs across providers, monitor outcomes, and initiate changes in care as necessary to provide the health home prompt notification of an individual’s admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting and address immediate needs in order to maximize optimum care and timely treatments, services and referrals. * Responsible for overseeing the team maintaining the security of all data files and employment of approved methods of data encryption to prevent theft of personally identifiable information up to HIPAA standards.* Provide and/or contribute to the annual performance evaluations of staff including the documentation of disciplinary actions and the development of professional goals. * Provide direct member coverage as needed.* Cooperate with any and all investigations conducted by the Agency, funding sources and any other authorized agencies/entities.* 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 issues* Performs other related duties as requested or assigned by agency management QUALIFICATIONS:* Master’s Degree in Social Work, Nursing, Public Health or other related social service orhealth profession* NYS RN, NP, LMSW/LCSW CASAC, License or a Licensed Psychologist preferred. * 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 to coordinates staff coverage. * Ability to work flexible hours and days – including weekends/evenings/holidays according to needs of a 24/7 program.* Ability to travel in the community and use public transportation.* Fluency in second language preferredBENEFITS:* 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: www.ccbq.org EOE/AA.