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
• Completes/revises an individualized patient-centered plan or care with the patient to identify patient’s needs/goals, and includes family members and other social supports as appropriate
• Consults with multidisciplinary team on patient’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
• Prepares patient crisis intervention plan
• Coordinates with service providers and health plans as appropriate to secure necessary care, share crisis intervention and emergency information
• Links individuals with Serious Mental Illness (SMI), developmental disabilities, or substance use disorders (SUD) to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services)
• Conducts case conferences annually with interdisciplinary team to monitor and evaluate patient status.

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 two (2) years 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

What Evergreen Health Offers You:

• Multiple comprehensive medical health insurance plans for you to choose from
• Dental and Vision coverage at no cost to you
• Paid Time Off package that equals 4 weeks of time in your first year
• 403b with a generous company match
• Paid parking or monthly metro pass
• Professional development opportunities
• Paid lunch breaks