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About the Role

The Care Coordinator is responsible for coordinating all aspects of an assigned health home member’s care, facilitating access to medical and psychosocial services, and monitoring data regarding health home members. The role focuses on integrating physical health and mental needs, ensuring enrollees receive necessary follow-up care, and re-engaging patients who have become lost to care.

Responsibilities

Engage and retain 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.
Facilitate care transitions and social/community services.
Develop, manage, and coordinate comprehensive, individualized, person-centered care plans.
Ensure priority appointments for members to care services.
Promote evidence-based wellness and prevention by linking members with resources.
Reassess needs for Health Home services and review clinical measurements.
Identify potential barriers to successful care and resolutions.
Complete contact notes, incident reports, and other required documentation.
Maintain accurate recordings in electronic case files.
Conduct outreach via phone to health home members between visits.
Monitor member completion of post-visit follow-up.
Aid members in identifying primary care physicians and multidisciplinary teams.
Maintain the security of all data files and employ approved methods of data encryption.
Refer health home members to peer supports and coordinate peer supports, support groups, and self-care programs.
Assure timely and comprehensive transitional care from inpatient facilities.
Develop and maintain health home networks with various providers and organizations.
Utilize and electronically track all specialty medical, behavioral, and support service referrals.
Ensure members follow up and receive all necessary care.
Track and arrange appointments.
Educate health home members.
Coordinate all aspects of the member’s health and community services.
Ensure members’ entitlements, insurance, and benefits are in place.
Provide interpreter services as required.
Provide direct service provision of services to the consumer based on needs.
Provide holiday coverage as required.
Provide 24/7 availability for information and emergency consultation.
Provide escorts to health home members from ER, hospital, and other settings.
Report issues that may negatively impact the agency, client, or staff welfare.
Cooperate with investigations conducted by the Agency, funding sources, and other authorized agencies.

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.
Skills in crisis intervention.
Time management skills.
Psychosocial rehabilitation skills.
Ability to link clients to a broad range of services.
Excellent communication skills.
Cross-cultural competency.
Outreach skills.
Interviewing skills.
Listening skills.
Advocating skills.
Linking skills.
Negotiating skills.
Engagement skills.
Monitoring skills.
Clinical assessment skills.
Excellent computer skills.
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.
Ability to talk, hear, walk, stand & sit.
Ability to lift up to 10 pounds.
Ability to climb stairs and make home visits.
Ability to stretch and bend to retrieve files.
Ability to operate a computer keyboard, mouse, & office equipment.
Ability to sit and work on the computer for long periods of time.
Ability to travel to multiple locations as needed.

Skills

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

Location

Brooklyn
Queens

Work Type

Full-time
24 hours/seven days a week 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

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.
The Care Coordination program offers services to adults and children ages 6 to 18 enrolled in the Coordinated Behavioral Care (CBC) Health Home Program with a history of serious mental illness and/or multiple hospitalizations.
The goal is to connect clients and families to various community resources identified as beneficial to the clients’ overall holistic well-being in order to reduce emergency room visits, inpatient stays and criminal justice involvement.

Equal Opportunity

EOE/AA