Health​/HH Plus Care Coordinator

Position: Health Home/HH Plus Care Coordinator
Location: New York

# Health Home/HH Plus Care Coordinator Hot Job
2681 Marion Avenue Residence - Bronx, NY 10458## Overview Salary Range $50,000.00 - $54,000.00 Salary Position Type Full Time Job Shift Day Education  Level4 Year Degree## Description
** JOB SCOPE:
** As a member of the Care Coordination team and under the supervision of the Program Supervisor/Team Leader, the Health Home / Health Home Plus (HH+) Care Coordinator provides comprehensive, person-centered and intensive care management to adults with complex behavioral health, medical, substance use, housing, and social-service needs. The position serves individuals enrolled in Medicaid Health Home, including members who meet HH+ criteria such as high-need Serious Mental Illness (SMI) and Assisted Outpatient Treatment (AOT), and may also serve assigned non-Medicaid care coordination cases.

The Care Coordinator maintains a total caseload of up to 20 individuals, adjusted as appropriate for acuity, HH+ requirements, program needs, and applicable regulatory standards.

This is a field-intensive position serving Manhattan, the Bronx, and Brooklyn. The Care Coordinator meets members where they are - including homes, shelters, hospitals, psychiatric inpatient units, detoxification/rehabilitation programs, outpatient clinics, and community agencies - and plays a central role in transitions of care, engagement, service coordination, advocacy, crisis prevention, and continuity of treatment. The goal is to promote stability, wellness self-management, community tenure, and successful connection to medical, behavioral health, housing, benefits, and social supports while reducing avoidable emergency department use and hospitalization.
*
* ESSENTIAL FUNCTIONS:

*
* · Manage an assigned caseload of up to 20 HH, HH+, and/or non-Medicaid care coordination members, providing services according to member acuity, risk, eligibility, individualized needs, and applicable program requirements.
· Provide required Health Home core services and HH+ enhanced services, including comprehensive care management, care coordination and health promotion, transitional care, member/family support, and referrals to community and social supports. Ensure required service intensity and face-to-face contacts are completed for HH+ and AOT members.
· Conduct frequent field-based visits throughout Manhattan, the Bronx, and Brooklyn, including member homes, shelters, hospitals, inpatient and outpatient treatment settings, and community agencies.
· Complete comprehensive assessments and develop, implement, monitor, and update person-centered Plans of Care addressing behavioral health, medical, substance use, housing, benefits, social, functional, safety, and other identified needs, strengths, preferences, and goals.
· Coordinate care and maintain effective communication with medical, behavioral health, substance use, hospital, housing, managed care, family/support, and community providers, including interdisciplinary case conferences and follow-up on referrals and treatment recommendations.
· Coordinate transitions of care from hospitals, emergency departments, psychiatric inpatient units, detox/rehabilitation programs, and other institutional settings; complete timely post-discharge follow-up to support medication access, appointments, transportation, housing, benefits, and continuity of treatment.
· Provide assertive outreach, engagement, and re-engagement for members who miss appointments, disengage from treatment, cannot be located, or are at risk for loss of continuity of care, including required diligent-search activities.
· Assess and monitor member risk, functioning, and changes in condition; provide crisis intervention, safety planning, advocacy, and timely escalation/coordination with…