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About the Role
Partner with individuals with I/DD, their families, and providers to coordinate care and services, aiming to enhance health, wellness, independence, and community integration. Provide Health Home core services including comprehensive care management, care coordination, health promotion, transitional care, individual and family support, referrals, and utilize Health Information Technology. All services will be delivered with a person-centered approach.
Responsibilities
- Conduct comprehensive assessments to identify clinical and psychosocial needs, choices, and preferences.
- Assess and address health and safety issues, barriers to care, and social determinants of health.
- Collaborate with interdisciplinary teams and incorporate input into assessments and Life Plans.
- Facilitate, develop, and maintain person-centered Life Plans integrating personal wants, needs, clinical/non-clinical healthcare needs, community services, OPWDD services, and natural supports.
- Incorporate health promotion and support opportunities for individuals to achieve optimal health.
- Adhere to Incident Management regulations, guidelines, and policies.
- Coordinate and ensure access to chronic disease management.
- Facilitate referrals to clinical and community resources, including planning, implementation, and follow-up for care management and transitional care.
- Participate in internal and external audits.
- Coordinate and provide access to long-term care supports and services.
- Engage families and natural supports in the care coordination process.
- Provide culturally and linguistically appropriate services.
- Advocate on behalf of the individual.
- Promote self-advocacy and self-direction.
- Utilize Health Information Technology for documentation, service linkage, and team communication.
- Secure all health records and protected information, adhering to confidentiality and HIPAA regulations.
- Maintain compliance with all state and federal laws, regulations, Medicaid compliance, and PCC policies.
- Document all services and maintain records according to policies.
- Complete all required training.
- Perform other relevant duties as requested.
Requirements
- Ability to act quickly and assess/act in crisis situations.
- Intermediate technology skills in Outlook, Teams, Word, Excel, and online applications.
- Understanding of EHR system usage.
- Knowledge of ethical and professional responsibilities and boundaries.
- Demonstrate professional work habits including dependability, time management, organization, autonomy, and productivity.
- Must be able to travel throughout covered territories in Upstate NY.
- Must have a valid driver’s license.
- Ability to conduct in-person visits and meetings at individuals' homes, communities, schools, and other locations.
- Ability to work remotely, satellite office locations, and/or primary office location.
- Adhere to all Prime Care Coordination policies and procedures.
- Adhere to the Agency Mission, Vision, Shared Values, and Customer Service Standards.
- Attend mandatory education and training modules as scheduled.
- Maintain all required certifications/training by State regulations and PCC policy.
- Act as a professional representative of PCC in regard to appearance, behavior, temperament, communication, language, and dress.
Skills
- Care Management
- Care Coordination
- Health Promotion
- Transitional Care
- Individual and Family Support
- Referral Services
- Health Information Technology
- Person-Centered Approach
- Assessment
- Crisis Intervention
- Collaboration
- Documentation
- HIPAA Compliance
- Medicaid Compliance
- Advocacy
- Self-Advocacy Promotion
- Self-Direction Promotion
- Cultural Competency
- Linguistic Appropriateness
- Time Management
- Organization
- Autonomy
- Productivity
- Bi-lingual skills (some positions)
Location
- Upstate NY
- Remote
- Satellite office locations
- Primary office location
Work Type
- Full-time
- Remote
- Hybrid
Experience Level
- Two years of relevant experience (with Bachelor's degree)
- Two years of relevant experience (with RN license)
- One year of relevant experience (with Master's degree)
Education Level
- Bachelor's degree
- Registered Nurse (RN) license
- Master's degree
Benefits
- Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
About the Company
- Prime Care Coordination is committed to equal employment opportunity.
- Prime Care Coordination will make reasonable accommodations for known physical or mental limitations of otherwise qualified employees and applicants with disabilities unless the accommodation would impose an undue hardship on the operation of our business.
Equal Opportunity
- We recruit, employ, train, compensate, and promote without regard to race, religion, color, national origin, age, sex, disability, protected veteran status, or any other basis protected by applicable federal, state, or local law.
- If you are interested in applying for an employment opportunity and feel you need a reasonable accommodation pursuant to the ADA, please contact us at 585-347-1037.