JOB SCOPE:

As a member of the Care Coordination team and under the supervision of the Program Supervisor, the Care Coordinator is responsible for addressing all member needs, providing care plan updates, and conducting outreach to members in 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. Care Coordinators advocate and support members, engaging with community agencies/health care providers, and others on the member’s behalf to ensure access to necessary services that promote wellness, self-management, and reduce emergency room visits and/or hospitalizations.

ESSENTIAL FUNCTIONS:

Responsibilities include but are not limited to the following:

• coordinates care for a caseload of 30-35 members;
• maintains monthly contact with all members of assigned caseload, with increased contact for newly enrolled and high-risk members;
• upon handoff from the Outreach Team, conduct member engagement activities, including face-to-face, mail, electronic, and telephone contact;
• 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 documents, records, statistics, and other related reports in an organized, timely, and accurate manner as per policy and procedure;
• conduct initial and periodic needs assessments, including assessing barriers and assets (i.e., 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 helping members in understanding care plans and instructions and tailoring communications to appropriate health literacy levels;
• record client progress according to measurable goals described in his/her care plan;
• assist members with accessing healthcare and social systems, including arranging for transportation and scheduling and accompanying members to appointments;
• assist members with identifying available community-based resources and actively manage appropriate referrals, access, engagement, follow-up, and coordination of services;
• assist with coordinating members’ access to individual and family supports and resources.;
• assist members with managing daily routines related to healthcare and incorporating members’ strengths and identifying barriers;
• assist with conducting outreach and engagement activities that support continuity of care, including re-engaging members in care if they miss appointments and/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 to assess members' needs;
• manage wrap-around funds, metro cards and checks for member purchases, including obtaining the necessary approvals for all purchases in keeping with the member’s goals.

• Bachelors degree and two years of related human services experience in providing direct services to individuals with chronic health and/or behavioral health disorders.