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About the Role

As a member of the Care Coordination team, the Care Coordinator addresses all member needs, provides care plan updates, and conducts outreach. This role utilizes a Health Home service model to provide care coordination to NYC Medicaid beneficiaries with chronic health and/or behavioral health disorders. Care Coordinators advocate for members, engage with community agencies and healthcare providers to ensure access to services, aiming to improve self-management and reduce hospitalizations.

Responsibilities

Coordinates care for a caseload of 40-50 members.
Maintains monthly contact with all members of the assigned caseload, increasing contact for newly enrolled and high-risk members.
Conducts member engagement activities upon handoff from the Outreach Team, including face-to-face, mail, electronic, and telephone contact.
Establishes and maintains effective communication with primary and specialty care physicians, substance abuse and mental healthcare providers, family, collateral resources, and other agency staff on behalf of members.
Maintains documents, records, statistics, and other related reports in an organized, timely, and accurate manner.
Conducts initial and periodic needs assessments, including assessing barriers, assets, member and family/caregiver preferences, and language, literacy, and cultural preferences.
Assists with the development and execution of member's care plans, tailoring communications to appropriate health literacy levels.
Records client progress according to measurable goals described in their care plan.
Assists members with accessing healthcare and social systems, including arranging transportation and scheduling/accompanying members to appointments.
Assists members with identifying available community-based resources and actively manages referrals, access, engagement, follow-up, and coordination of services.
Assists with coordinating members' access to individual and family supports and resources.
Assists members with managing daily routines related to healthcare, incorporating members' strengths, and identifying barriers.
Assists with conducting outreach and engagement activities that support continuity of care, including re-engaging members in care if they miss appointments or do not follow up on treatment.
Provides crisis intervention and follow-up.
Monitors member entitlements, insurance, and other benefits to ensure they remain active.
Advocates for members to resolve crises.
Collaborates with other professionals to evaluate members' medical or behavioral health condition and assess member needs.
Responsible for emergency on-call for 2 to 3 weeks out of the year.
Manages wrap-around funds, metro cards, and checks for member purchases, obtaining necessary approvals.

Requirements

High School Diploma and CASAC plus four (4) years of related human services experience in providing direct services to individuals with chronic health and/or behavioral health disorders.
Associate Degree in Human Services, Psychology, Rehabilitation, Nursing, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Health, Physical or Recreational therapy, plus three (3) years of related human services experience.
Bachelor’s Degree in Social Work, Psychology, Education, Rehabilitation, Nursing, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Hearing, Physical or Recreational therapy, plus two (2) years of related human services experience.
Master’s Degree in Social Work, Psychology, Education, Rehabilitation, Nursing, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Health, Physical or Recreational therapy, plus one (1) year of related human services experience.
In rare circumstances, staff may have unique education and/or experience to adequately serve the HH+ SMI population but do not meet the qualifications outlined above and the agency may submit a waiver and encourage those to still apply.

Location

New York, NY

Work Type

Full Time

Experience Level

4 years of related human services experience
3 years of related human services experience
2 years of related human services experience
1 year of related human services experience

Education Level

High School Diploma
CASAC
Associate Degree
Bachelor’s Degree
Master’s Degree

Salary/Compensations

$25.83 - $27.48 Hourly