Care Coordinator N

Care Coordinator:

Are you looking to join a dynamic team focused on providing high quality health care to communities across Brooklyn & Queens? If so, you’ve come to the right place. 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.

Catholic Charities provides comprehensive care coordination and treatment services to individuals living with serious mental illness, complex medical needs and substance use needs. Under the NYC Department of Health and Mental Hygiene, our Non-Medicaid Care Coordination Program works with individuals who do not qualify for Medicaid and are living with serious mental illness, to deliver comprehensive, community-based services and ensure clients have access to uninterrupted and coordinated behavioral and physical health services while addressing the social determinants of health that impact daily living.

Care Coordinators address a host of issues that impact clients directly such as housing, access to nutritious food, economic security/benefits, medication adherence, linkage with outpatient treatment providers or other community resources and social supports.

RESPONSIBILITIES:

The Care Coordinator has overall day-to-day responsibility and accountability for coordinating all aspects of an individuals’ care with complex and/or psychiatric co-morbid conditions and for facilitating their access to the full range of medical and psychosocial services in an efficient and effective manner. Individuals are provided care in their home/community at least twice monthly, and more frequently if needed. Duties of the Care Coordinator focus on integration and coordination of physical health, mental health and overall social needs.

The Care Coordinator must become an active participant in all phases of care transition to assure that enrollees received all required mental and medical follow up care and services and re-engagement of patients who have become lost to care. The Care Coordinator electronically monitors and tracks data regarding the individual and alerts all members of the Care Team when follow-up is required.

• Accountable for engaging and retaining individuals in care, coordinating and arranging for the continuous provision of services, supporting adherence to treatment recommendations, monitoring and evaluating their 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.

• In collaboration with the client, 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.

• Ensures the availability of priority appointments for clients to care services including physical, psychiatric, and substance use within their provider network to avoid unnecessary, inappropriate utilization of emergency room and inpatient hospital services.

• Promotes evidence-based wellness and prevention by linking health home members with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources and other medical services based on individual physical needs and preferences.

• Tracks and shares client information and care needs across providers by utilizing electronic databases and monitors outcomes and initiate changes in care, as necessary, to address client needs.

• Reassesses needs for services and reviews clients’ historical or targeted clinical measurements (i.e. number of ER visits and inpatient psychiatric admissions).

• Identifies potential barriers to successful care…