Description

Service Coordinator

Brockport, NY

Description

Position Summary:

The Service coordinator works directly with providers and caregivers in order to communicate the most comprehensive care to a patient. The Service Coordinator is responsible for assisting patients with finding and obtaining community services required for individuals to stay healthy and out of the hospital and emergency room. These patients may be referred by providers/clinical team; or enrolled in NYS Health Home Program or be included in care management as part of a grant, insurance program or disease specific program. 

Skills/Qualifications:

· Ability to assess, monitor and evaluate patients’ needs

· Strong ties to community resources 

· Clear written and verbal commination

Spanish Language Skills Preferred

Responsibilities: 

· Responsible for referring patients to needed services as directed by provider to support care plan/treatment goals; including medical/behavioral health. 

· Consult with multidisciplinary team and assist in developing patients’ care plan/needs/goals, this may include participation in case conferencing and may include family members and social supports. 

· Assist in developing individualized plans and community supports to overcome obstacles that would prevent them from receiving needed services / referrals

· Follow up with Hospitals/ ER upon notification of admission or discharge and coordinate with health care team to facilitate communication of the event and transition of care services, to include, but not limited to medication reconciliation with the health care team as per policy.

· Provide basic instruction/health education to clarify provider instructions, procedures and referral needs.

· Schedule and maintain client visits, follow-up calls, and provider engagements utilizing effective time management skills.

· Prepare concise, accurate and timely case notes in eClinicalWorks (eCW) 

· Responsible for release of all necessary clinical information to specialist referrals, tracks referral appointments and obtains consultant reports with appropriate consent for release of information and documents process in eCW per OOH procedure 

· Conduct client outreach and engagement activities at least monthly to evaluate for on-going emerging needs and to promote continuity of care and improved health outcomes. 

Requirements

Required Education and Experience:· 

• Bachelor’s Degree in Health or Human Services related field. 
• Two years’ experience working with individuals with chronic medical conditions, intellectual and/or developmental disabilities, or mental health issues. 
• Care Management experience preferred. 
• Equivalent combination of education and/or experience from which comparable knowledge, skills and abilities have been achieved may be considered.