Evergreen Health

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 .
• 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 .
• Links and refers patients to needed services to support care plan including medical, behavioral health , patient education, and entitlement programs.
• Follows up with patient upon notifications of ER or inpatient admission and or/ discharge and facilities transitions of care within 24-48 hours.
• Advocate for interpretation services and utilizes translation lines as needed .
• Conducts diligent search activities to ensure patient engagement and to assess on-going emerging needs in order to promote continuity of care and improve health outcomes .
• Prepare clients crisis interventions plan and coordinates with services providers and health plans as appropriate to secure necessary care, share crisis intervention and emergency information .

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 one (1) year 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