Care Coordinator - 00277 (HHM050) - Mon-Fri 9AM-5PM

Position Summary:

Care Coordinators are responsible for working collaborative with their clientele, all their support systems to include community providers to insure support for overall health and wellness.

Essential Accountabilities:

• Conduct outreach activities through various methods and engage individuals with chronic medical conditions, mental health issues, and/or substance use disorders, often co-occurring.
• Conduct initial and ongoing comprehensive assessments to determine strengths and identified needs.
• Prepare and revise care plans to reflect client needs and personal goals with a focus on maintaining health and wellness.
• Maintain contact with clients at least monthly, and more often as needed, providing telephonic as well as face to face outreach, engagement, and comprehensive service planning in the field.
• Advocate for and support clients to ensure access to resources necessary to support wellness/self-management and decrease frequency of emergency room visits and inpatient hospital admissions.
• Monitor and coordinate all care for clients, including access and maintenance of medical insurance, linkage to treatment providers and community resources.
• Collaborate with community providers at least monthly as part of a multi-disciplinary team to ensure goal-directed care planning.
• Conduct crisis intervention when needed and follow up accordingly.
• Maintain detailed, timely, and accurate record keeping in an electronic medical record. Coordinate with supervisor, office manager, and health home outreach team in a timely manner to ensure accurate caseload status (including enrollments, closures, and screen outs).
• Complete all required monthly documentation as required to ensure continuity of engaged clients’ medical insurance and to ensure appropriate and accurate billing.
• Work as part of a care management team, attend and participate in weekly team meeting to provide feedback and share resource information relating to client needs, issues and concerns.
• Be responsible for reporting/coordinating daily office and field schedules with other members of the team and supervisor
• Offer resources and serve as a consultant to all team members on medical/psychosocial/substance use issues as well as social service needs.
• Attend periodic trainings to enhance skill level and learn about wellness self-management and best practice skills.
• Participate in bi-weekly individual supervision to address concerns/issues and improve skill development.
• Be responsible for agency vehicles, including upkeep, documentation, and gas card when assigned.
• Be responsible for agency cell phone, laptop, and associated items.
• Follow program guidelines as outlined in the personnel manual.
• Report to the program administration any issues and/or concerns on a regular/as needed basis while working in the field.

Other Responsibilities:

• Maintain confidentiality at all times.
• Participate in activities of other staff members in their absence or during periods of staff shortage.
• Represent the agency at meetings, trainings not otherwise specified.
• Ability to work flexible schedule as work schedule and locations are subject to change

Bachelor’s degree and two years’ experience in Human Services required; New York State driver’s license and access to a vehicle required