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About the Role

The Care Specialist is responsible for coordinating all aspects of care for assigned health home serving children members with complex medical and/or psychiatric co-morbid conditions. This role facilitates access to community services, focusing on the integration and coordination of physical health, mental health, and social service needs.

Responsibilities

• Coordinate all aspects of care for assigned health home serving children members.
• Facilitate access to the full range of medical, behavioral health, substance use, social, and psychosocial services in the community.
• Integrate and coordinate physical health, mental health, and social service needs.
• Actively participate in all phases of care transition to ensure members receive required mental and medical follow-up care and services.
• Take action around re-engagement of members who have become lost to care.
• Electronically monitor and track data regarding health home members and alert the Care Team when follow-up is required.
• Engage and retain Queens health home members in care.
• Coordinate and arrange for the continuous provision of services.
• Support adherence to treatment recommendations.
• Monitor and evaluate member needs, including prevention, wellness, medical, specialist, and behavioral health treatment, care transitions, and social and community services.
• Develop, manage, and coordinate a comprehensive individualized person-centered care plan.
• Ensure the availability of priority appointments for health home members to care services.
• Promote evidence-based wellness and prevention by linking members with resources.
• Track and share health home members’ information and care needs across providers.
• Monitor outcomes and initiate changes in care as necessary.
• Reassess needs for Health Home services and review historical or targeted clinical measurements.
• Complete contact notes, incident reports, and other required documentation.
• Maintain accurate recordings in electronic case files in a timely fashion.
• Complete CANS-NY training and examination.
• Conduct outreach via phone to health home members between visits.
• Monitor that the health home member completes post-visit follow-up.
• Conduct monthly face-to-face visits with client/child and monthly follow-up with various providers/collaterals.
• Aid health home members in identifying primary care physicians and multidisciplinary teams.
• Refer Queens health home members to peer supports and coordinate peer supports, support groups, and self-care programs.
• Ensure timely and comprehensive transitional care from an inpatient facility.
• Develop and maintain health home networks with various providers and organizations.
• Utilize regional health information organizations (RHIOs) and other data systems to track and share member information.
• Utilize and electronically track all specialty medical, behavioral, and support service referrals.
• Ensure the member follows up and receives all necessary care.
• Track and arrange appointments, educate health home members, and coordinate all aspects of the member’s health and community services.
• Provide direct service provision of services to the consumer based on needs.
• Provide holiday coverage as required.
• Provide 24 hours/7 days a week availability for information and emergency consultation services.
• Provide escorts to health home members from ER, hospital, and other settings to alternative levels of care.
• Report behavioral health services administration and/or agency administration issues that may negatively impact the agency, client, or staff welfare.
• Cooperate with investigations conducted by the Agency, funding sources, and other authorized agencies/entities.

Requirements

• Bachelor’s degree in social work, psychology, or a related health/human services field with two (2) years of direct work with the target population.
• OR Degree/certification in Medical and Clinical Assistance or Health professional field.
• Requires CANS-NY certification.
• Ability to link clients to a broad range of services essential to successfully living in a community setting.
• Excellent communication skills.
• Cross-cultural competency, outreach, interviewing, listening, advocating, linking, negotiating, engagement, monitoring, and clinical assessment skills are essential.
• Excellent computer skills are necessary.
• Knowledge of community medical resources and their financial requirements.
• Good oral and written communication skills.
• Ability to work flexible hours and days – including weekends/evenings/holidays according to needs of a 24/7 program.
• Regularly required to talk, hear, walk, stand & sit.
• Able to lift up to 10 pounds.
• Able to climb stairs and make home visits.
• Able to stretch and bend to retrieve files.
• Able to operate a computer keyboard, mouse, & office equipment.
• Able to read printed materials and computer screens.
• Able to write.
• Able to sit and work on the computer for long periods of time.
• Able to travel to multiple locations as needed.

Skills

• Crisis intervention
• Time management
• Psychosocial rehabilitation skills
• Linking clients to services
• Communication skills
• Cross-cultural competency
• Outreach
• Interviewing
• Listening
• Advocating
• Linking
• Negotiating
• Engagement
• Monitoring
• Clinical assessment
• Computer skills
• Knowledge of community medical resources
• Oral communication skills
• Written communication skills
• Second language fluency preferred

Location

• Brooklyn
• Queens

Work Type

• Full-time
• 24/7 program availability

Experience Level

• Two (2) years of direct work with the target population

Education Level

• Bachelor’s degree in social work, psychology or a related health/human services field
• Degree/certification in Medical and Clinical Assistance or Health professional field
• CANS-NY certification

Benefits

• Competitive salary
• 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
• Other additional voluntary benefits

About the Company

• For over 125 years, Catholic Charities Brooklyn and Queens has been providing quality social services to the neighborhoods of Brooklyn and Queens.
• Offers 160-plus programs and services for children, youth, adults, seniors, and those struggling with mental illness.
• Provides individuals with serious mental illness, complex medical needs and substance abuse issues with comprehensive care coordination and case management services.
• Our Children’s Care Coordination team works with the New York State Health Homes Program to help children and families meet their goals and live well cared for in the community.
• The program serves children/youth and their families ages 0-21.
• Helps children and families get the support they need to address healthcare goals and gain access to timely and efficient services within their community of choice.

Equal Opportunity

• EOE/AA