The posting
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. The Care Coordination program offers services to adults and children ages 6 to 18 enrolled in the Coordinated Behavioral Care (CBC) Health Home Program with a history of serious mental illness and/or multiple hospitalizations. The goal is to connect clients and families to various community resources identified as beneficial to the clients’ overall holistic well-being in order to reduce emergency room visits, inpatient stays and criminal justice involvement. STATEMENT OF THE JOB Under the direct supervision of the HH Team Supervisor, the Care Specialist has overall day-to-day responsibility and accountability for coordinating all aspects of care for assigned health home serving children members with complex medical and/or psychiatric co-morbid conditions and for facilitating their access to the full range of medical, behavioral health, substance use, social and psychosocial services in the community, in an efficient and effective manner. Duties of the Care Specialist focus on integration and coordination of physical health, mental health and social service needs. The Care Specialist has to become an active participant in all phases of care transition to assure that members receive all required mental and medical follow up care and services, and must also take action around re-engagement of members who have become lost to care. The Care Specialist electronically monitors and tracks data regarding health home member and alerts all members of the Care Team when follow-up is required. DUTIES AND RESPONSIBILITIES
Demonstrates commitment to the vision of Health Home and strategic priorities to ensure their achievement. Accountable for engaging and retaining Queens health home members 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 health home members, 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 health home members to care services including physical, psychiatric, and substance abuse within their health home 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 health home members’ information and care needs across providers by utilizing electronic databases and monitors outcomes and initiate changes in care, as necessary, to address health home members’ needs. Reassesses needs for Health Home services and reviews health home members’ historical or targeted clinical measurements (i.e. number of ER visits and inpatient psychiatric admissions). Identifies potential barriers to successful care and resolutions to those barriers.
Completes contact notes, incident reports, and other required documentation and maintains accurate recordings in electronic case files in a requested timely fashion. Completes CANS-NY training and examination to properly assess clients being served Monthly Face to face visit with client/child as well as monthly follow up (telephonic or face to face) with various providers/collaterals (i.e. guidance counselors, parents/guardians, therapists, ACS etc.) Responsible for direct service provision of services to the consumer based on needs as established and documented in comprehensive assessments and service plans. This will be re-evaluated and adjusted in the care coordination platform every 6 months or as needed (per goal change or change in life event) 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 health home members from ER, hospital and other settings to alternative level of care. As this is an evolving program, additional responsibilities may be added and/or revised.
SPECIFICATIONS FOR EDUCATION/CERTIFICATIONS/LICENSES
Bachelor’s degree in social work, psychology or a related health/human services field
SPECIFICATIONS FOR EXPERIENCE AND TRAINING
The position requires a combination of skills in the areas of crisis intervention, time management, psychosocial rehabilitation skills Must obtain CANS-NY certification upon employment. Ability in linking clients to a broad range of services essential to successfully living in a community setting (e.g., medical, psychiatric, social, educational, legal, housing and financial services). Must have excellent communication skills. Cross-cultural competency, outreach, interviewing, listening, advocating, linking, negotiating, engagement, monitoring and clinical assessment skills are essential. Excellent computer skills are necessary. Knowledge of the community medical resources and their financial requirements. Good oral and written communication skills. Fluency in second language preferred.
SPECIFICATIONS FOR PHYSICAL REQUIREMENTS
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 stretch and bend to retrieve files. Able to operate a computer keyboard, mouse, & office equipment. Able to read printed materials and computer screens. Able to write. Able to sit and work on the computer for long periods of time. Able to travel to multiple locations as needed.
BENEFITS We offer competitive salary and excellent benefits including:
Generous time off (Vacation/ Personal Days/ Sick Days/ Paid Holidays annually) Medical, Dental Vision Retirement Savings with Agency Match Transit Flexible Spending Account Life insurance Public Loan Forgiveness Qualified Employer Training Series and other additional voluntary benefits.
For more information on our organization, please visit our website at: www.ccbq.org EOE/AA.
