SCOPE OF ROLE:

The Care Coordinator provides services in the Clinical Home and in the community to HIV-positive clients living with complex medical conditions, severe mental illness, substance abuse and long-term care needs and a history or risk of over-utilizing medical and behavioral health services.

ESSENTIAL DUTIES & RESPONSIBILITIES:

-Help find, engage, and enroll clients from the NYS DOH list of eligible Brooklyn and Manhattan Medicaid beneficiaries who have chronic illness and possible mental illness and or substance abuse
-Assure that clients reliably attend medical appointments at outpatient clinics
-Assure that clients comply with prescription regiment
-Write clear service plans and progress notes and maintain meticulous documentation of service visits
-Carry a caseload of clients, each of which is to be visited once and at least one service provided during the course of a calendar month
-Coordinate ancillary care for clients to ensure continuous, comprehensive care
-Collaborate with all members of the team, primary care and specialty doctors and all partners on a regular basis
-Initiate appropriate referrals to additional services including home care and notify appropriate support staff of referral to ensure authorization
-Assist clients to obtain access to transportation
-Research, evaluate and recommend community resources to meet non-medical needs of client (i.e. alternative resource programs, support groups and community support services.)
-Work with Medical Home team inpatient providers, discharge planners and nurse partners to ensure efficient use of inpatient resources and a timely discharge to an appropriate setting
-Facilitate and participate in client care conference for medical and peer review
-Collaborate with mental health and substance abuse care providers to ensure coordination of all services and integration of services
-Work collaboratively with the ValueOptions Field Care Coordinator to provide and link clients to services that facilitate illness management
-Provide verbal and written illness management educational protocols
-Immediately reports serious incidents, serious incident allegations, incidents, or sensitive situations to supervisors. Completes incident reports in accordance with CIDP policy

Locations available: Bronx 

Bilingual English/Spanish is strongly preferred.

We are offering Flexible Hybrid schedules and reimbursement for travel.

Benefits Overview: We offer attractive compensation with comprehensive benefits including: Medical/Dental/Prescription/Vision/Life Insurance; 403(b); Credit Union; FSAs; Short-and-Long-Term Disability; Transportation Plan; Generous Paid Vacations and Holidays

REQUIRED EDUCATION AND EXPERIENCE

-B.A. degree in a related field
-2 years’ experience in providing direct services to mentally disabled clients or in linking mentally disabled clients to a broad range of services essential to successfully living in the community.

PREFERRED QUALIFICATIONS & SKILLS

-Basic knowledge of mental illness and serious emotional disturbances
-Basic knowledge of treatment, rehabilitation, and community support programs as they relate to clients, families and staff
-Bilingual English/Spanish