The Care Coordinator will be responsible for providing comprehensive care management services to individuals across various healthcare settings in NYC or Long Island. This role involves coordinating medical and social services, developing individualized care plans, and ensuring effective communication among healthcare providers, patients, and their families. The Care Coordinator will work closely with multidisciplinary teams to optimize patient outcomes and enhance the quality of care.
Essential Accountabilities:
- Conduct outreach activities through various methods and engage individuals with chronic medical conditions, mental health issues, and/or substance use disorders, often co-occurring.
- Conduct initial and ongoing comprehensive assessments to determine strengths and identified needs.
- Prepare and revise care plans to reflect client needs and personal goals with a focus on maintaining health and wellness.
- Maintain contact with clients at least monthly, and more often as needed, providing telephonic as well as face to face outreach, engagement, and comprehensive service planning in the field.
- Advocate for and support clients to ensure access to resources necessary to support wellness/self-management and decrease frequency of emergency room visits and inpatient hospital admissions.
- Monitor and coordinate all care for clients, including access and maintenance of medical insurance, linkage to treatment providers and community resources.
- Collaborate with community providers at least monthly as part of a multi-disciplinary team to ensure goal-directed care planning.
- Conduct crisis intervention when needed and follow up accordingly.
- Maintain detailed, timely, and accurate record keeping in an electronic medical record. Coordinate with supervisor, office manager, and health home outreach team in a timely manner to ensure accurate caseload status (including enrollments, closures, and screen outs).
- Complete all required monthly documentation as required to ensure continuity of engaged clients’ medical insurance and to ensure appropriate and accurate billing.
- Work as part of a care management team, attend and participate in weekly team meeting to provide feedback and share resource information relating to client needs, issues and concerns.
- Be responsible for reporting/coordinating daily office and field schedules with other members of the team and supervisor
- Offer resources and serve as a consultant to all team members on medical/psychosocial/substance use issues as well as social service needs.
- Attend periodic trainings to enhance skill level and learn about wellness self-management and best practice skills.
- Participate in bi-weekly individual supervision to address concerns/issues and improve skill development.
- Be responsible for agency vehicles, including upkeep, documentation, and gas card when assigned.
- Be responsible for agency cell phone, laptop, and associated items.
- Follow program guidelines as outlined in the personnel manual.
- Report to the program administration any issues and/or concerns on a regular/as needed basis while working in the field
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Other Responsibilities:
- Maintain confidentiality at all times.
- Participate in activities of other staff members in their absence or during periods of staff shortage.
- Represent the agency at meetings, trainings not otherwise specified.
- Ability to work flexible schedule as work schedule and locations are subject to change
