JOB SUMMARY:

The Care Coordinator functions as a member of an interdisciplinary team to provide care coordination to a caseload of severely mentally ill adults with multiple medical comorbidities and/or co-occurring substance abuse disorders and/or medically ill individuals.  Advocates for and supports the client, engages with community agencies/health care providers and others on his behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations. Provides clinical support to the Team by providing consultation, education, information around psychosocial and/or substance abuse conditions, interventions, resources to maintain focus on outcomes and best practices.

ESSENTIAL JOB FUNCTION: List all essential job duties.  (To perform this job successfully, an individual must be able to perform each essential duty listed satisfactorily with or without a reasonable accommodation.  Reasonable accommodations may be made to enable qualified individuals with a disability to perform the essential duties unless this causes undue hardship to the agency.)

Conducts initial and ongoing assessments of assigned clients to document strengths, needs, goals, and resources. Participates in the development/documentation /review and update of client centered comprehensive integrated, interdisciplinary care plan in consultation with other team members to ensure focus on desired outcomes. Maintains effective communications with clients, primary care physicians, substance abuse, and mental healthcare providers, family, collateral resources and other Agency staff on behalf of clients. Maintains documents, records, statistics, and other related reports in an organized, timely, and accurate manner as per policy and procedure. Coordinates care planning with other providers of services/ resources to ensure goal directed, collaborative care, including care transitions. Works as part of a Care Coordination team; attends and participates in team meetings to provide input/feedback around psychosocial and medical conditions conditions/comorbidities to review client status, update plans and goals, review outcomes to further program goals. Acts as a resources/consultant to all team members on psychosocial, medical and/or substance abuse issues and resources. Provides telephonic as well as face-to-face outreach, engagement, and service planning in the field. Acts as a linkage to community services including medical, behavioral, residential, entitlement and any other needed services per interdisciplinary care plan. Monitors overall service delivery to clients to ensure coordination and continuity; advocates with service providers/resources as needed. Provides crisis intervention and follow-up. May be assigned other tasks and duties reasonably related to the job responsibilities. And other duties as may be assigned

ESSENTIAL KNOWLEDGE, SKILLS AND ABILITIES: 

Working knowledge of computer software and electronic health record systems Demonstrated competency in written, verbal, and computational skills to present and document records in accordance with program standards. Experienced in and demonstrated comprehensive understanding and working knowledge of the interdisciplinary planning process and the developmental treatment model. Knowledge of Medicaid, Social Security and other entitlements preferred. Excellent interpersonal skills required. You must have the ability and willingness to regularly travel, in some instances with clients in Agency vehicles, to many locations using various modes of reliable and safe transportation

TRAINING REQUIREMENTS

Specific training for the designated assessment tool(s), the array of services and supports available, and the client-centered service planning Training in assessment of individuals whose condition may trigger a need for HCBS and supports, and an ongoing knowledge of current best practices to improve health and quality of life. Mandated training on the New York State Community Mental Health Assessment instrument and additional required training.

 

QUALIFICATIONS AND EXPERIENCE: 

A bachelor’s degree in one of the fields listed below1; or A NYS teacher’s certificate for which a bachelor’s degree is required; or NYS licensure and registration as a Registered Nurse and a bachelor’s degree; or A Bachelor’s level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses; or A Credentialed Alcoholism and Substance Abuse Counselor (CASAC).

1 Qualifying education includes degrees featuring a major or concentration 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

AND two years of experience:

In providing direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or In linking individuals with Serious Mental Illness, developmental disabilities, or substance use disorders to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services).

A master’s degree in one of the qualifying education fields may be substituted for one year of experience.