Health Home Plus HH Care Coordinator NassauSuffolk

The HH+ Care Coordinator functions as a member of an interdisciplinary team to provide care coordination to a caseload of severely mentally ill adults with multiple medical co morbidities and/or co-occurring substance abuse disorders. HH+ Care Coordinators advocate for and support the client, engage with community agencies/health care providers and others on his/her behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations. Conduct appropriate screening and either performing or arranging for more detailed assessments when needed (e.g., high-risk substance use or mental health related indicators, harm to self/others, abuse/neglect and domestic violence). Navigating the mental health service system-including ability to make referrals to mental health housing services, crisis intervention/ diversion, peer support services Collaborates with inpatient staff and MCO (as applicable) to affect successful transitions out of inpatient or institutional settings Conduct hospital visits for clients admitted for inpatient psychiatric treatment Share and collaborate discharge summaries with outpatient care teams Addressing the quality, adequacy and continuity of services to ensure appropriate support for individuals' mental health and psychosocial needs. Maintain engagement with individuals who are often disengaged from care, have difficulty adhering to treatment recommendations, or have a history of homelessness Develop service plans and resolve barriers to effective service utilization. Accompany clients to/from any appointments when needed. Document service information in databases and use electronic systems to track participant activities. Assist in crisis intervention and provide or refer to crisis services. Extensive field work required, including home visits and community work such as visiting hospitals and emergency rooms when determined necessary. Assist with applications for entitlements such as (but not limited to): SNAP, SSI/SSD, HEAP Ensure that clients follow-up with aftercare discharge (i.e. fill prescriptions, make appointments). Skills and/or Experience Required: For B.A. level candidates, two (2) years

OR

for M.A. level candidates, one (1) year of related experience working with individuals with severe mental illness. Ability and willingness to regularly travel, in some instances with clients in Agency vehicles to many locations using various modes of reliable and safe transportation You must have excellent interpersonal and time management skills. Proficiency in email and documentation on electronic platforms. Comfortable with fieldwork and navigating social services systems. Preferred: Knowledge of Medicaid, Social Security and other entitlements Bilingual /Spanish a plus Bilingual /Creole a plus Benefits Competitive Salary Medical/Dental 401k (with company match) Profit Sharing Employee Referral Program Supplemental Benefits Paid Time off Holidays

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