POSITION OVERVIEW:

Care Coordinators link adults and children with chronic behavioral health and medical conditions to the services they need to stay as healthy as possible and inspire the people they serve (members) to use those services to optimize their health outcomes. Working in a team setting and primarily in the field, Care Coordinators assess risk and needs, develop person centered care plans, provide care management services, track and arrange appointments, educate members and coordinate other aspects of members’ health and community services. As this is an evolving program, additional responsibilities will be added.

EDUCATIONAL/TRAINING REQUIRED:

• A bachelor’s degree with a major or concentration (minimum of 24 credits) 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 A NYS teacher’s certification for which a bachelor’s degree is required; OR NYS licensure and registration as a Registered Nurse and a bachelor’s degree PLUS Two years of experience in providing direct services, or a substantial number of case management services, to mentally disabled or chronically ill or homeless individuals, or children which complex social or healthcare needs.

OR

• A Bachelor’s Degree, Associates Degree or High School Diploma/GED in another discipline PLUS five years’ experience working with an applicable population.
• Specific experience with the target population may be required to work with Children, Health Home Plus or Adult Home Plus members.

EXPERIENCE REQUIRED/LANGUAGE PREFERENCE:

• Experience working in interdisciplinary teams; experience providing care management or care coordination in a medical or behavioral health environment; experience working with the chronically ill.
• Fluency in a second language such as Spanish, Russian, or Creole

COMPUTER SKILLS REQUIRED:

• Use of an Electronic Health Record (EHR)
• Use of Outlook and related Microsoft Office Applications

PURPOSE:

The Jewish Board’s Community Care Management programs provide compassionate, high quality, evidence-based services to individuals and families in the communities we serve. Our staff use a culturally competent, person centered approach to help individuals and their families develop skills and resources to improve overall functioning, to instill hope, and to strengthen resiliency. Our programs work closely with community partners to address health disparities in our neighborhoods while also celebrating the strengths and resilience of our communities. Care Management is a service that helps adults with chronic illnesses get and use the medical, social and community services they need to stay healthy. Care Coordinators help members figure out and take the actions needed to get and stay healthy-making it to appointments, sticking to a medication schedule, and access benefits.

RESPONSIBILITIES INCLUDE BUT ARE NOT LIMITED TO:

• Integration of medical, specialized, and behavioral health services in addition to social support and/or educational support services
• Periodic assessment of a member’s medical and behavioral health needs as well as compliance with recommended treatments
• Collaborative development of an Individualized Care Plan (ICP) with the member, the member’s family and/or caregivers in addition to other service providers
• Providing required care management services
• Tracking all specialty medical, behavioral and support service referrals made for patient using Health Information Technology (HIT) provided.
• Assuring that member has access to, engages in and retains needed services as defined in the member’s ICP. Such services may include: Acute Medical Care; Primary Medical Care; Preventative medical care services (including metabolic screening); Home Health Care; Chemical Dependency Services; Behavioral Health Services; Community social support services; Housing; State and federal entitlements; Educational services; Involvement with child welfare, juvenile justice or criminal justice institutions.
• Providing outreach services to members for increased access to the above services
• Responding to members’ information and referral questions.
• Reassessing the need for ongoing care coordination services
• Completing all required documentation
• Sharing knowledge and experience with other team members to support the team’s overall service provision efforts
• Carrying an agency-provided cell phone
• Responding to member crises during (and occasionally outside of) regular business hours
• Other duties as assigned