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About the Role

The Care Coordinator-HH+ works with an assigned caseload of clients enrolled in the Health Home Plus (HH+) program, delivering enhanced care coordination services. This includes at least two face-to-face visits and two other core services per month. For clients also enrolled in the Health and Recovery Plan (HARP), the role assists with accessing Home and Community Based Services (HCBS) and Community Oriented Recovery and Empowerment Services (CORE). Responsibilities include conducting eligibility assessments, developing and maintaining HCBS Plans of Care, and linking clients to community providers.

Responsibilities

Maintain a caseload of clients enrolled in Health Home Plus (HH+) and HARP and provide care coordination services in compliance with health home policy and standards of care.
Work with the program manager to determine and establish HH+ eligibility for each client on their assigned caseload.
Conduct home visits with clients and travels into the community to meet with clients in other community-based settings, including medical provider appointments, hospitals, residential settings, and other community service provider offices.
Conduct comprehensive assessment and develop a patient-centered Plan of Care to address client needs.
Assist clients with achieving their goals, in accordance with the Plan of Care.
Complete crisis plan with all client on assigned caseload and review with client at least annually.
Conduct annual case review with client and members of the client’s care team to review the Plan of Care and address barriers that prevent client from meeting their Plan of Care goals.
Successfully complete the HARP Assessment training in the Uniform Assessment System for New York (UAS-NY).
Performs HARPs assessments/reassessments; maintains an active Health Commerce System (HCS) account.
Monitor the delivery of HCBS services to ensure clients are following through with goals identified in their HCBS care plans.
Assist client with coordination of appointments including but not limited to scheduling, rescheduling, providing appointment reminders and arranging transportation.
Works closely with the interdisciplinary care team including primary care providers, medical specialists, mental health providers, residential services, substance abuse treatment program, etc.
Conduct research on community resources and government benefit programs to determine eligibility criteria, provide appropriate referrals, and perform follow up activities for referrals.
Utilize culturally sensitive and linguistically appropriate strategies to engage and deliver services to clients.
Accurately document all interactions with clients and all efforts made towards client engagement.
Submit all progress notes within 48 hours of the client encounter.
Collaborate and case conference with the MCO HARP Care Manager, HCBS, and CORE providers to ensure on-going client linkage and engagement in HCBS and CORE.
Effectively utilize electronic systems, including Netsmart, HEALTHeLink, PSYCKES, and ePACES.
Provide education to other members of the Care Coordination Division team on HARP, HCBS, and CORE and assists with transferring of newly HAREP enrolled clients between caseloads as needed.
Attend agency and department in-service training and staff meetings as well as any other agency related activities as required.
Effectively support health home programs on an as needed basis.

Requirements

Bachelor's degree in child & family studies, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreation therapy, rehabilitation, social work, sociology, or speech and hearing AND Two (2) years of experience providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism, or substance abuse, and/or children with SED
Bachelor's level education or higher in any field with three years of experience working directly with persons with behavioral health diagnoses
Bachelor's level education or higher in any field and two (2) years of experience as a Health Home care manager serving the SMI or SED population.
Exhibited ability to effectively work within an inclusive and culturally and linguistically diverse environment.
Strong internet research and computer skills, especially with Outlook, Word, Excel, PowerPoint, and web-based health information systems.
English speaking and writing fluency required.
Demonstrate basic knowledge of chronic conditions, including chronic mental conditions, HIV/AIDS, and serious mental illness.
Must have access to a reliable vehicle, possess a valid, clean NYS driver’s license and be sufficiently self-insured with liability insurance in the amount of $100,000/$300,000.

Skills

Bilingual skills desirable.
Judgment and Decision Making
Time Management
Communication Intelligence
Adaptability & Flexibility
Client Focus
Initiative & Adaptability

Location

Office
Community

Work Type

Full-time
Flexible hours, including days and some evenings, late nights, and weekends.

Experience Level

Two (2) years of experience providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism, or substance abuse, and/or children with SED
Three years of experience working directly with persons with behavioral health diagnoses
Two (2) years of experience as a Health Home care manager serving the SMI or SED population.

Education Level

Bachelor's degree in child & family studies, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreation therapy, rehabilitation, social work, sociology, or speech and hearing
Bachelor's level education or higher in any field

Salary/Compensations

$27.00 to $29.00 hourly

Benefits

Health, Dental, and Vision insurance.
Accrued Paid Time Off (PTO) of 4+ weeks.
401k retirement plan with agency contribution of 4%.
13+ observed holidays annually.
Reduced full-time work week of 35 hours and early close on Fridays.

About the Company

For more than 150 years, Jewish Family Services of Western New York has been committed to providing high quality services to all in need in the interest of helping to "repair the world."
Our services are guided by the essential connection between mental well-being, physical wellness, and positive self-worth.
Our reputation is the result of our exceptional staff.
In addition to offering competitive compensation and truly exceptional benefits, we are committed to providing a supportive work environment in which all employees are able to contribute their best.
Be a Mensch: We are ethical, kind, and admirable. We assume good intent and act with integrity. We are thoughtful and deliberative in how we support our clients, each other, and the community. “Choose generosity over judgment—every time”
Be Purpose-Built: We create spaces and programs that respect clients’ individuality and opens access. We strive to meet the individual where they’re at and give them the tools to be successful
Be Resolute: We work with tenacity to identify problems, seek out solutions, and get things done. Even small steps forward are acts of resilience.

Equal Opportunity

Jewish Family Services of Western New York is an equal opportunity employer.
We celebrate diversity and are committed to creating an inclusive environment for all employees.