Children's Health Home Care Coordinator

About the role

The Care Coordinator is a member of the Care Coordination team, responsible for addressing all member needs, providing care plan updates, and conducting outreach to members between visits. Care Coordinators provide care coordination to NYC Medicaid beneficiaries with chronic health and/or behavioral health disorders using a Health Home service model. They advocate and support members, engage with community agencies and healthcare providers, and ensure access to services that increase wellness self-management and reduce emergency room visits and/or hospitalizations.

Responsibilities

• Coordinate care for a caseload of 40-50 members.
• Maintain monthly contact with all members of the assigned caseload, with increased contact for newly enrolled and high-risk members.
• Conduct member engagement activities (face-to-face, mail, electronic, and telephone) upon handoff from the Outreach Team.
• Establish and maintain effective communication with primary and specialty care physicians, substance abuse and mental healthcare providers, family, collateral resources, and other agency staff on behalf of members.
• Maintain organized, timely, and accurate documentation, records, statistics, and related reports as per policy and procedure.
• Conduct initial and periodic needs assessments, including assessing barriers and assets (e.g., transportation, community barriers, social supports), member and family/caregiver preferences, and language, literacy, and cultural preferences.
• Assist with the development and execution of members’ care plans, including tailoring communications to appropriate health literacy levels and helping members understand care plans and instructions.
• Record client progress according to measurable goals described in their care plan.
• Assist members with accessing healthcare and social systems, including arranging transportation and scheduling and accompanying members to appointments.
• Help members identify available community-based resources and actively manage appropriate referrals, access, engagement, follow-up, and coordination of services.
• Coordinate members’ access to individual and family supports and resources.
• Assist members with managing daily routines related to healthcare, incorporating members’ strengths, and identifying barriers.
• Conduct outreach and engagement activities to support continuity of care, including re-engaging members who miss appointments or do not follow up on treatment.
• Provide crisis intervention and follow-up.
• Monitor member entitlements, insurance, and other benefits to ensure they remain active and in place.
• Advocate for members to resolve crises.
• Collaborate with other professionals to evaluate members’ medical or behavioral health conditions and assess member needs.
• Responsible for emergency on-call duties for 2 to 3 weeks out of the year.
• Manage wrap-around funds, metro cards, and checks for member purchases, including obtaining necessary approvals for all purchases in keeping with the member’s goals.

Requirements

Candidates must meet one of the following education and experience combinations:

• High School Diploma and CASAC, plus four (4) years of related human services experience in providing direct services to individuals with chronic health and/or behavioral health disorders.
• Associate Degree in Human Services, Psychology, Rehabilitation, Nursing, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Hearing, Physical or Recreational Therapy, plus three (3) years of related human services experience.
• Bachelor’s Degree in Social Work, Psychology, Education, Rehabilitation, Nursing, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Hearing, Physical or Recreational Therapy, plus two (2) years of related human services experience.
• Master’s Degree in Social Work, Psychology, Education, Rehabilitation, Nursing, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Hearing, Physical or Recreational Therapy, plus one (1) year of related human services experience.

*In rare circumstances, staff with unique education and/or experience serving the HH+ SMI population who do not meet the above qualifications may apply with a waiver.