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About the Role
The Ulster County care coordinator will work with Medicaid-enrolled individuals living with mental illness or multiple chronic conditions to connect them to care and services in their local communities. This role aims to reduce duplicate services, emergency department visits, and inpatient admissions by connecting high-risk Medicaid individuals to resources and supports, thereby improving health and well-being in Ulster County. The population served has unmet mental health, addiction, or social determinant of health needs and typically does not engage with traditional systems of care. The goal is to support individuals in identifying goals and making connections to needed services.
Responsibilities
- Assists participants with psychiatric diagnoses to participate in diverse, person-centered, self-directed services and meaningful activities that promote empowerment and robust recovery.
- Collaborates with the SPOA (Single Point of Access) for referrals.
- Maintains regular contact, outreach, curriculum development, group facilitation, counseling, mentoring, systems navigation, community oversight, and crisis support.
- Provides Care Management outreach and engagement with eligible individuals in coordination with the Institute of Family Health and Care Management Partners of Ulster County.
- Provides screenings and evaluations using trauma-informed, person-centered skills with the Institute of Family Health’s service tools, along with individual advocacy, peer support, and systems navigation.
- Educates participants on useful health & wellness topics, including Peer/Self-help, smoking cessation, and advocacy.
- Helps participants identify barriers to their recovery journeys or personal wellness, including access, quality of care, people’s rights, lack of basic needs, and stigma & discrimination.
- Advocates for participants to overcome identified barriers, ensuring their voices are heard and decisions are understood and respected.
- Builds peer-to-peer connections/relationships based on mutuality, empathy, and hope for recovery/wellness.
- Assists participants to identify & accomplish whole health goals related to the Eight Dimensions of Wellness.
- Directly connects participants to services and supports through direct bridging/linking.
- Develops and maintains positive working relationships with other provider agencies and local housing providers.
- Documents all meaningful interactions with participants in electronic records software and maintains hard copies in participants’ files daily.
- Submits monthly reports in a timely manner and attends related meetings.
- Aligns all behaviors with core values that promote trauma-informed care, customer engagement and satisfaction, mutuality & empathy, and a commitment that everyone can and will recover.
- Takes action to represent the rights and interests of individuals living with mental illness or trauma by removing barriers to their recovery and wellness.
- Conducts peer support sessions (one-to-one, groups) that promote possibilities for positive change.
- Directly supports, assists, and guides individuals as they access various resources in the community related to their health, wellness & overall quality of life.
- Uses Epic Compass Rose regularly for documentation and billing requirements.
- Assesses clients’ needs, educates them on community-based resources, directly links them to those resources, and works to ensure quality, integrated care.
- Addresses questions about healthcare, managing stress, appointments, medications, food, transportation, housing, health insurance, and other services as needed.
- Maintains timely and accurate documentation, files, and databases; compiles and submits program statistics and reports; and attends weekly supervisory meetings.
- Participates in mandatory professional development and training.
- May include other duties as they arise.
Requirements
- Requires a thorough understanding of the process and the possibility of robust recovery for people diagnosed with psychiatric disabilities.
- People with personal experience as a recipient of mental health services and/or of personal recovery are preferred.
- Knowledge of ADA, mental health laws and systems, Social Security Programs, Work Incentives, Entitlement Programs, supported employment, Federal/state/local services, laws, and systems related to individuals with disabilities.
- Demonstrated ability to recognize the need for and facilitate connections between participants and services.
- Knowledge of local, statewide, and national disability-related issues and community dynamics.
- Excellent written and verbal presentation skills.
- Ability to obtain the NYS Peer Specialist Certification within 6 months of active employment.
- Must have a valid and clean driver's license.
- Experience shall consist of providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse, and/or children with SED.
- Experience shall consist of linking individuals with Serious Mental Illness, children with SED, developmental disabilities, and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting.
Skills
- Psychiatric Rehabilitation perspective
- SAMHSA’s Eight Dimensions of Wellness
- Trauma-informed care
- Customer engagement and satisfaction
- Mutuality & empathy
- Peer support
- Systems navigation
- Data entry
- Care management
- Documentation
- Reporting
- Professional development
- Training
Location
- Kingston NY
Work Type
- Monday through Friday – 9:00 AM to 5:00 PM (40 Hours Per Week)
Experience Level
- One (1) year of experience with a Master’s degree
- Two (2) years of experience with a Bachelor’s degree
- Three (3) years of experience with a Bachelor’s degree in any field
- Two (2) years of experience as a Health Home care manager serving the SMI or SED population with a Bachelor’s degree in any field
- Two (2) years of experience with a Credentialed Alcoholism and Substance Abuse Counselor (CASAC)
Education Level
- Master’s degree in social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field
- Bachelor’s degree in social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field
- Bachelor’s degree in any field
- Credentialed Alcoholism and Substance Abuse Counselor (CASAC)
Salary/Compensations
- $24.50 per hour
About the Company
- People USA – Non-Profit Peer Run Behavioral Health, Mental Health, Recovery, Wellness