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About the Role

Responsible for assessing and engaging clients in health and wellness, and developing comprehensive care plans. This role involves collaborating with care teams and providers to ensure optimal client health outcomes.

Responsibilities

• Develops rapport with clients to engage them in improving their health and wellness.
• Administers standardized health and psychosocial risk screenings according to Health Home protocols and timeframes.
• Utilizes health screenings to identify interventions and develop a comprehensive care plan.
• Collaborates with care team members to identify needs and develop a plan for optimal health outcomes.
• Implements care plan tasks and ensures follow-up and continuity of care.
• Regularly reviews and updates the care plan.
• Documents all interventions and attempted contacts in the EHR.
• Works with care providers to address Gaps in Care.
• Assesses domiciled clients' living conditions by conducting home visits.
• Works with family members and collaterals to facilitate care planning and delivery.
• Provides comprehensive transitional care following hospitalization events.
• Reviews new information and complex cases with PCP and multidisciplinary team, incorporating recommendations.
• Facilitates care delivery by scheduling appointments, obtaining information, and arranging transportation.
• Utilizes evidence-based practices, such as motivational interviewing, to empower clients.
• Collaborates with team members and provides support as needed.
• Identifies community resources and makes referrals.
• Supports client goals and serves as an advocate.
• Administers CSD funds and submits required documentation.
• Participates in team meetings and weekly clinical conferences.
• Attends in-service training.
• Performs duties as assigned by supervisor.

Requirements

• B.A. or M.A. degree in social services or related field.
• Two years of experience providing direct service in the human service field, nursing, or CM/Service Coordination.
• Strong written and verbal communication skills.
• Bilingual English/Spanish preferred.

Skills

• Health and wellness assessment
• Care plan development
• Health and psychosocial risk screening
• Collaboration
• Intervention implementation
• Continuity of care
• EHR documentation
• Home visits
• Transitional care
• Motivational interviewing
• Community resource identification
• Referral making
• Client advocacy
• CSD fund administration

Location

• Manhattan
• Queens

Work Type

• Full-time

Experience Level

• Two years of experience

Education Level

• B.A. or M.A. degree

Salary/Compensations

• $60,419

Benefits

• Generous benefits

About the Company

• ACMH is committed to the mental and physical wellbeing of vulnerable New Yorkers and is a leader in the provision of outreach and engagement, care management, rehabilitation, crisis support, and supportive housing.
• ACMH is committed to becoming an anti-racist organization and seeks to promote actionable change to create an intentional culture of equity at individual, interpersonal and institutional levels.
• For more information, visit our website: www.acmhnyc.org

Equal Opportunity

• ACMH is an equal opportunity employer and does not discriminate in employment decisions based on race, color, creed, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, mental or physical disability, marital status, veteran status or citizenship status.