Postgraduate Center for Mental Health
Job Scope
As a member of the Care Coordination team and under the supervision of the Program Supervisor, the Care Coordinator is responsible for addressing all member needs, providing care plan updates, and conducting outreach to members in between visits. Care Coordinators provide care coordination to NYC Medicaid beneficiaries with chronic health and/or behavioral health disorders using a Health Home service model. Care Coordinators advocate and support members, engaging with community agencies/health care providers, and others on the member’s behalf to ensure access to necessary services that promote wellness, self‑management, and reduce emergency room visits and/or hospitalizations.
Essential Functions & Responsibilities
Coordinates care for a caseload of 30-35 members.
Maintains monthly contact with all members of assigned caseload, with increased contact for newly enrolled and high‑risk members.
Upon handoff from the Outreach Team, conduct member engagement activities, including face‑to‑face, mail, electronic, and telephone contact.
Establishes and maintains effective communication with primary and specialty care physicians, substance abuse and mental healthcare providers, family, collateral resources, and other agency staff on behalf of members.
Maintains documents, records, statistics, and other related reports in an organized, timely, and accurate manner as per policy and procedure.
Conducts initial and periodic needs assessments, including assessing barriers and assets (e.g., transportation, community barriers, social supports), member and family/caregiver preferences, and language, literacy, and cultural preferences.
Assists with the development and execution of members’ care plans, helping members understand care plans and instructions and tailoring communications to appropriate health literacy levels.
Records client progress according to measurable goals described in their care plan.
Assists members with accessing healthcare and social systems, including arranging for transportation and scheduling and accompanying members to appointments.
Assists members with identifying available community‑based resources and actively manages appropriate referrals, access, engagement, follow‑up, and coordination of services.
Assists with coordinating members’ access to individual and family supports and resources.
Assists members with managing daily routines related to healthcare and incorporating members’ strengths while identifying barriers.
Assists with conducting outreach and engagement activities that support continuity of care, including re‑engaging members in care if they miss appointments or do not follow up on treatment.
Provides crisis intervention and follow‑up.
Monitors member entitlements, insurance, and other benefits to ensure they remain active and in place.
Advocates for members to resolve crises.
Collaborates with other professionals to evaluate members’ medical or behavioral health conditions and to assess members' needs.
Manages wrap‑around funds, metro cards and checks for member purchases, including obtaining the necessary approvals for all purchases in keeping with the member’s goals.
Qualifications
Education: A bachelor’s degree.
Experience: Two years of related human service experience in providing direct services to individuals with chronic health and/or behavioral health disorders.
Seniority level Entry level
Employment type Full‑time
Job function Other
Industries Mental Health Care
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Essential Functions & Responsibilities
Coordinates care for a caseload of 30-35 members.
Maintains monthly contact with all members of assigned caseload, with increased contact for newly enrolled and high‑risk members.
Upon handoff from the Outreach Team, conduct member engagement activities, including face‑to‑face, mail, electronic, and telephone contact.
Establishes and maintains effective communication with primary and specialty care physicians, substance abuse and mental healthcare providers, family, collateral resources, and other agency staff on behalf of members.
Maintains documents, records, statistics, and other related reports in an organized, timely, and accurate manner as per policy and procedure.
Conducts initial and periodic needs assessments, including assessing barriers and assets (e.g., transportation, community barriers, social supports), member and family/caregiver preferences, and language, literacy, and cultural preferences.
Assists with the development and execution of members’ care plans, helping members understand care plans and instructions and tailoring communications to appropriate health literacy levels.
Records client progress according to measurable goals described in their care plan.
Assists members with accessing healthcare and social systems, including arranging for transportation and scheduling and accompanying members to appointments.
Assists members with identifying available community‑based resources and actively manages appropriate referrals, access, engagement, follow‑up, and coordination of services.
Assists with coordinating members’ access to individual and family supports and resources.
Assists members with managing daily routines related to healthcare and incorporating members’ strengths while identifying barriers.
Assists with conducting outreach and engagement activities that support continuity of care, including re‑engaging members in care if they miss appointments or do not follow up on treatment.
Provides crisis intervention and follow‑up.
Monitors member entitlements, insurance, and other benefits to ensure they remain active and in place.
Advocates for members to resolve crises.
Collaborates with other professionals to evaluate members’ medical or behavioral health conditions and to assess members' needs.
Manages wrap‑around funds, metro cards and checks for member purchases, including obtaining the necessary approvals for all purchases in keeping with the member’s goals.
Qualifications
Education: A bachelor’s degree.
Experience: Two years of related human service experience in providing direct services to individuals with chronic health and/or behavioral health disorders.
Seniority level Entry level
Employment type Full‑time
Job function Other
Industries Mental Health Care
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