Targeted Case Manager; 4153-203-A

at  Catholic Charities Brooklyn and Queens

For over 125 years, Catholic Charities Brooklyn and Queens has been providing quality social services to the neighborhoods of Brooklyn and Queens, and currently offers 160-plus programs and services for children, youth, adults, seniors, and those struggling with mental illness.
Targeted Case Management (TCM), specifically the COBRA HIV/AIDS TCM and the OMH TCM, plays a significant role in assisting eligible Medicaid individuals gain access to needed medical, behavioral, and social services. With implementation of Health Homes, the Department of Health’s Medicaid program, AIDS Institute, and the Office of Mental Health developed the following draft guiding principles and scenarios to help understand the role of TCMs relative to Health Homes. These documents discuss TCMs and “converted” TCMs. Converted TCMs are Medicaid enrolled targeted case management programs that, once approved by the State, are designated Health Homes, or participate in a State approved Health Home network.

QUALIFICATIONS:

• 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 Professional Degree/certification in healthcare field.
• Cross-cultural competency, outreach, interviewing, listening, advocating, linking, negotiating, engagement, monitoring and clinical assessment skills are essential.
• Fluency in second language preferred
• Ability to work flexible hours and days – including weekends/evenings/holidays according to needs of a 24/7 program.
• Regularly required to talk, hear, walk, stand & sit.
• Able to lift up to 10 pounds.
• Able to climb stairs and make home visits.
• Able to travel to multiple locations as needed.

• In conjunction with interdisciplinary team, is accountable for engaging and retaining client in care, arranging for the continuous provision of services, supporting adherence to treatment recommendations, monitoring and evaluating client needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care.
• Outreach via phone to clients between visits (check on self-care, medication fills, treatment plan, schedules visits, tests/follow-up); monitors that the client completes post-visit follow-up (fill prescriptions, make appointments).
• Conduct comprehensive assessments to develop a person-centered and recovery-oriented Care Plan.
• Coordinate care across the spectrum of health services, including access to high-quality physical health (both acute and chronic) and behavioral health care, as well as social services, housing, educational systems, entitlements/benefits and employment opportunities as necessary to facilitate wellness and recovery of the whole person.
• In collaboration with interdisciplinary team, clients, their family and/or caregivers, and other service providers, develops, manages and coordinates a comprehensive individualized person-centered care plan that coordinates and integrates the continuum of medical, behavioral health services, rehabilitative, long term care and social service needs and clearly identifies the primary care physician/nurse practitioner, specialists, behavioral health care providers, care manager and other providers directly involved in the individual’s care.
• Ensure the availability of priority appointments for CCBHC clients to treatment services including physical, psychiatric, and substance abuse within their health provider network to avoid unnecessary, inappropriate utilization of emergency room and inpatient hospital services.
• Assist clients and families of children and adolescents in obtaining appointments and keeping the appointment when there is a referral to an outside provider, subject to privacy and confidentiality requirements and consistent with consumer preference and need.
• Aid CCBHC clients in identifying the primary care physician and multidisciplinary teams of medical, mental health, chemical dependency treatment providers, social workers, nurse’s nutritionists/dieticians, pharmacists, outreach workers including peer specialists and other care providers to assure that enrollees receive needed medical, behavioral, and social services in accordance with a plan of care.
• Refer CCBHC clients to peer supports, support groups, and self-care programs to increase client’s and caregivers knowledge about the individual’s diseases; promote client’s engagement and self-management capabilities in their participation in care plan development and decision making.
• Complete progress notes, incident reports, and other required documentation and maintain accurate recordings in electronic case files in a requested timely fashion.
• Verify CCBHC clients receive test results; monitor medical directives follow-up. Prepare and follow-up on a list of CCBHC clients who need preventive or metabolic screening, appointment reminders; work with CCNS Nurses.
• Participate with interdisciplinary team in tracking clients admitted to and discharged from the following facilities: emergency departments, hospital outpatient clinics, urgent care centers, residential crisis settings, and substance use disorder treatment programs offering a continuum of care to include outpatient with induction services and maintenance treatment for MAT, intensive outpatient or partial hospital programs, or centers of excellence or those with a specialty in treating OUD and when clinically indicated inpatient and residential treatment programs.
• Assure timely and comprehensive transitional care from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing or treatment facility) to follow-up with post discharge interventions; transition/escort clients from inpatient settings back to the community and be an active leader in discharge planning with hospital teams- able to respond in person to hospitals upon learning a client is hospitalized.
• Utilize regional health information organizations (RHIOs) and other data systems to track and share clients’ information and care needs across providers, monitor their outcomes, and initiate changes in care as necessary to provide prompt notification of an individual’s admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting and address immediate needs in order to maximize optimum care and timely treatments, services and referrals.
• Able to utilize technology conferencing tools including audio, video and /or web deployed solutions and accountable for hand-held devices (I Phone, Blackberry, I Pad, Tablets, Laptops, etc.).
• Demonstrate commitment to the vision of the CCBHC and its strategic priorities to ensure their achievement.
• Work schedule includes holiday coverage to accommodate the coverage needs of the program when required. 24 hours/seven days a week availability to provide information and emergency consultation services and provide escorts to clients from ED, hospital and other settings to alternative level of care within community.
• Report to Integrated Health & Wellness Administration and/or Agency Administration issues that may have a negative impact on the reputation of the Agency, client and/or staff welfare or any corporate compliance issue.
• Cooperate with any and all investigations conducted by the Agency, funding sources and any other authorized agencies/entities.
• Request in a timely fashion scheduled vacation and time off request from the Clinical Director to ensure continuous coverage of program’s activities.
• Perform other related duties as requested or assigned by agency management.
• As this is an evolving program, additional responsibilities may be added and/or revised.
• Participate in committees as directed