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

SUS IS AN EQUAL OPPORTUNITY EMPLOYER

Join a team of employees who cares about the wellbeing of others.  We believe in fostering a culture built on our core values:  respect, integrity, support, maximizing individual potential and continuous quality improvement. 

S:US is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, or genetic information. S:US is committed to providing access, equal opportunity and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities, including allowance of the use of services animals. To request reasonable accommodation or if you believe such a request was improperly handled or denied, contact the Director of Benefits & Compensation at MyMedicalLeave@sus.org.