Care Coordinator DOH - Full-Time; 4401-203-N

For over 125 years, Catholic Charities Brooklyn and Queens has been providing quality social services to the neighborhoods of Brooklyn and Queens, and currently offers 160-plus programs and services for children, youth, adults, seniors, and those struggling with mental illness. 

Under the NYC Department of Health and Mental Hygiene, our Non-Medicaid Care Coordination Program works with individuals who do not qualify for Medicaid and are living with serious mental illness, to deliver comprehensive, community-based services and ensure clients have access to uninterrupted and coordinated behavioral and physical health services while addressing the social determinants of health that impact daily living. Care Coordinators address a host of issues that impact clients directly such as housing, access to nutritious food, economic security/benefits, medication adherence, linkage with outpatient treatment providers or other community resources and social supports.

STATEMENT OF THE JOB

Under the direct supervision of the Team Supervisor, the Care Coordinator has overall day-to-day responsibility and accountability for coordinating all aspects of an assigned  Department of Health clients’ care with complex medical and/or psychiatric co-morbid conditions and for facilitating their  access  to the full range of medical and psychosocial services in an efficient and effective manner. Care Coordinator responsibilities are consumer-centered, recovery-oriented activities in order to increase individuals’ capacity to manager their health and wellness, live a self-directed life and reach their full potential.  The duties of the Care Coordinator are to focus on integration and coordination of physical health and mental needs of DOHMH consumers.  The Care Coordinator has to become an active participant in all phases of care transition to assure that enrollees received all required mental and medical follow up care and services and re-engagement of consumers who have become lost to care.  One of the many goals of Care Coordination efforts is a high-quality, timely, safe, effective and equitable referral or transition.

DUTIES AND RESPONSIBILITIES

• Accountable for engaging and retaining consumers in care, coordinating and arranging for the continuous provision of services, supporting adherence to treatment recommendations, monitoring and evaluating their needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care.
• Contact assigned  individuals at  a minimum for 2 face-to-face visits per month (recommended) to 4 or more face-to-face visits per month based on client need as established and documented in Comprehensive Assessments and Service Plans.
• Reassesses needs for services and reviews consumers’ historical or targeted clinical measurements (i.e. number of ER visits and inpatient psychiatric admissions). Identifies potential barriers to successful care and resolutions to those barriers. Re-evaluate and adjust Comprehensive Assessments and Service plan  for the consumer  every 6 months or as needed (as per SOMH CAIRS requirements).
• Follow- up with rehabilitative, long term care and social service needs and clearly identifies the primary care physician/nurse practitioner, specialists, behavioral health care providers, care manager and other providers directly involved in the individual’s care.
• Promotes evidence based wellness and prevention by linking consumers with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other medical services based on individual physical needs and preferences.
• Tracks and shares consumers’ information and care needs across providers by utilizing electronic database and monitors outcomes and initiate changes in care, as necessary.
• Completes contact notes, incident reports, and other required documentation and maintains accurate recordings in electronic case files in a requested timely fashion.
• Checks that consumers receive test results and tracks that they follow up with medical directions.
• Able to help consumers to understand lab results, test results and other reports that impact on their physical and mental health.
• Assess the needs of the consumer in order to use service dollars to respond to consumer’s emergency needs (e. g., clothing, food, shelter, etc.) and to facilitate progress toward recovery-oriented goals (e. g. education, employment, self-development and enrichment, etc.).
• Providing services that prevent or resolve crisis in order to prevent unnecessary use of emergency rooms and/or inpatient services.  Assuring crisis intervention service 24 hours per day, 7 days per week.
• Work schedule includes holiday coverage to accommodate the coverage needs of the program when required.
• Provide linkages with the Assisted Outpatient Treatment (AOT) Coordinating Team will be basic to the program design.  A system for tracking and monitoring consumers with AOT involvement will be maintained;
• Aids the consumers in identifying the primary care physician and multidisciplinary teams of medical, mental health, chemical dependency treatment providers, social workers, nurses’ nutritionists/dieticians, pharmacists, outreach workers including peer specialists and other care providers to assure that consumers receive needed medical, behavioral, and social services in accordance with a plan of care.
• Responsible for maintaining the security of all data files and employ approved methods of data encryption to prevent theft of personally identifiable information
• Refer consumers to peer supports and coordinate peer supports, support groups, and self-care programs to increase client’s and caregivers knowledge about the individual’s diseases, promote the consumers’ engagement and self-management capabilities, and help the to improve adherence to their prescribed treatment order to allow them to make informed decisions.
• Assure timely and comprehensive transitional care from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing or treatment facility) to follow-up with post discharge interventions in order to prevent consumers’ avoidable readmission after discharge and to ensure proper and timely follow up care.
• Communicates with Staff Nurse, Consulting Psychiatrist and Director of Health Homes regarding high risk cases, linkage to other Health Home providers, quality control, documentation of enrollee contact/interventions and program statistics.
• Develops and maintains networks with primary medical and specialty practitioners and mental health providers, substance abuse service providers, community based organizations, managed care plans, emergency rooms, hospitals, and residential/rehabilitation settings, community-based services to ensure coordinated, and safe transition in care for consumers who require transfer to/from sites of care.
• Schedules and provides logistical support for regular care team case conferences and tracks patient-provider follow-up actions.
• Makes sure that health home members’ entitlements, insurance and benefits are in place. Provides interpreter services as required.
• Collaborate with program management in the identification of developing marketing strategies.
• Reports to Behavioral Health Services Administration and/or Agency Administration issues that may have a negative impact on the reputation of the Agency, client and/or staff welfare or any corporate compliance issue.
• Cooperates  with any and all investigations conducted by the Agency, funding sources and any other authorized agencies/entities

SPECIFICATIONS FOR EDUCATION/LICENSES/CERTIFICATIONS

• Bachelor’s degree in social work, psychology or a related health/human services field with two years of direct work with the target population orCertification in Health profession field. 

SPECIFICATIONS FOR EXPERIENCE AND TRAINING

• The position requires a combination of skills in the areas of crisis assessment, clinical intervention, time management, organizational skills, and psychosocial rehabilitation skills.
• Able to link clients to a broad range of services essential to successfully living in a community setting (e.g., medical, psychiatric, social, educational, legal, housing and financial services). 
• Cross-cultural competency, outreach, interviewing, listening, advocating, linking, negotiating, engagement, monitoring and clinical assessment skills are essential.
• Knowledge of the community medical resources and their financial requirements.
• Good oral and written communication skills.

SPECIFICATIONS FOR PHYSICAL REQUIREMENTS

• Ability to travel in the community including public transportation.
• Ability to work flexible hours and days – including weekends/evenings/holidays according to needs of a 24/7 program.
• Must be able to type and use a computer.
• Frequent sitting to write reports and when meeting with clients.
• Ability to read printed materials and computer screens.
• By signing below, I acknowledge that I have read and agree to fulfill the duties and responsibilities outlined in my job description.

BENEFITS

We offer competitive salary and excellent benefits including:

• Generous time off (Vacation/ Personal Days/ Sick Days/ Paid Holidays annually)
• Medical,
• Dental
• Vision
• Retirement Savings with Agency Match
• Transit
• Flexible Spending Account
• Life insurance
• Public Loan Forgiveness Qualified Employer
• Training Series and other additional voluntary benefits.

For more information on our organization, please visit our website at:

www.ccbq.org EOE/AA.