Job Details

Primary Purpose of Job:

The Health Home Plus Care Coordinator conducts outreach, assessment and service planning to coordinate care for participants with severe mental illness (SMI) who may also have substance use disorders and/or chronic medical conditions. Works closely with clients to implement goals identified during the intake, assessment, reassessment, and care plan process. Maintains contact with the client's extended family and support networks for coordination of care. Monitors client's progress in utilizing services to achieve better health care outcomes while containing costs. Field work required to maintain required contacts per month.

Principal Duties & Responsibilities:

1. Maintain a caseload of regular Health Home clients and/or Health Home Plus clients.
2. Complete the required billable contacts per month for each client.
3. Conduct home visits and community work in the field including visiting hospitals and emergency rooms.
4. Gather information for and/or conduct outreach, intake, assessment, re-assessments and care plans.
5. Provide care management to a caseload through the coordination of medical, mental health and substance use services.
6. Implement activities to facilitate participant engagement.
7. Participate in case conferences with health home team including, Case Managers and treatment providers.
8. Ensure entitlements, insurance, and benefits are in place.
9. Develop service plans and resolve barriers to effective service utilization.
10. Responsible for assisting Health Home team members in implementing individualized care plans.
11. Monitor client's progress in utilizing services (appointments, treatment, medication, etc.) through telephonic and direct contact.
12. Check that clients receive test results and track that clients follow up with medical directions.
13. Transport and escort clients to/from appointments when needed.
14. Collaborate on care issues with internal clinicians and the participant's assigned Health Home medical provider.
15. Document service information in databases and use electronic systems to track participant activities.
16. Assist in crisis intervention and provide or refer to crisis services.
17. Ensure that clients follow up with aftercare discharge (i.e. fill prescriptions, make appointments).

Knowledge, Skills & Abilities Required:

1. Master’s Degree in social work or related field plus one year of experience or Bachelor’s Degree in social work or related field plus two years of experience. CASAC or High School Diploma or educational equivalent and significant combination of education and experience in criminal justice or working with substance using and/or mentally ill population considered.
2. Experience providing medical, mental health or substance use focused care coordination services to individuals with Serious Mental Illness, developmental disabilities, substance use disorders, or linking those individuals to services required. Experience in criminal justice preferred.
3. Knowledge of health care environments, clinical terminology and health information systems strongly preferred.
4. Must have valid NYS (New York State) Driver’s License and be willing to transport clients to appointments using own vehicle. Must provide proof of valid NYS car insurance and Defensive Driving Certificate within 30 days of hire. Valid registration, inspection and Automobile Insurance Liability of a recommended minimum of 100,000/300,000 will also be evaluated upon hire.
5. Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills required.
6. Must be proficient in computer applications or other automated systems such as spreadsheets, Microsoft Office applications, calendar, email and/or database software necessary to perform work assignments.