Soloh Partners Inc
SCOPE OF ROLE:
The Care Coordinator provides services in the Clinical Home and in the community to 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.
RESPONSIBILITIES: Help find, engage, and enroll clients from the NYS DOH list of eligible Brooklyn and Manhattan Medicaid beneficiaries who have a 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 the 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 the non-medical needs of clients (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 conferences 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 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.
RESPONSIBILITIES: Help find, engage, and enroll clients from the NYS DOH list of eligible Brooklyn and Manhattan Medicaid beneficiaries who have a 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 the 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 the non-medical needs of clients (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 conferences 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 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.