Spectrum Health and Human Services

Care Coordinator II

Spectrum Health and Human Services, Buffalo

Agency Profile: Spectrum Health & Human Services respectfully partners with adults, children, and families as they recover from behavioral, emotional, mental health and/or substance related disorders by offering individualized and meaningful opportunities of hope, empowerment and support to achieve self-defined improvements in their quality of life.

Full-time: 1298 Main Street, Buffalo, NY

SUMMARY OF POSITION FUNCTION:

The Care Coordinator will apply the essential activities of case management which include assessment, planning, coordination, monitoring and evaluation with the core components (Comprehensive Case Management, Care Coordination & Health Promotion, Comprehensive Transitional Care, Patient and Family Support and Referral to Community & Social/Support Services). The Care Coordinator will be responsible for the following outcomes: to reduce utilization associated with avoidable and preventable inpatient stays, to reduce utilization associated with avoidable emergency room visits, to improve outcomes for person with mental health illness and/or substance use disorders and to improve disease-related care for chronic conditions.

MAJOR DUTIES AND RESPONSIBILITIES:

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Complete a comprehensive health assessment/reassessment inclusive of medical/behavioral/rehabilitative and long term care and social service needs.
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Complete/revise an individualized patient centered plan or care with the patient to identify patient’s needs/goals, and include family members and other social supports as appropriate.
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Consult with multidisciplinary team on client’s care plan/needs/goals.
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Conduct outreach and engagement activities to assess on-going emerging needs and to promote continuity of care and improved health outcomes.
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Consult with primary care physician and/or any specialists involved in the treatment plan.
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Prepare client crisis intervention plan.
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Coordinate with service providers and health plans as appropriate to secure necessary care, share crisis intervention and emergency information.
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Link/refer client to needed services to support care plan/treatment goals, including medical/behavioral health care; patient education, and self help/recovery, and self management.
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Conduct case conferences with an interdisciplinary team to monitor and evaluate client status.
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Advocate for services and assist with scheduling of needed services.
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Coordinate with treating clinicians to assure that services are provided and to assure changes in treatment or medical conditions are addressed.
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Monitor/support/accompany the client to scheduled medical appointments.
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Follow up with hospitals/ER upon notification of a client’s admission and/or discharge to/from an ER, hospital/residential/rehabilitative setting.
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Facilitate discharge planning from an ER, hospital/residential/rehabilitative setting to ensure a safe transition/discharge that care needs are in place.
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Notify/consult with treating clinicians, schedule follow up appointments, and assist with medication reconciliation.
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Link client with community supports to ensure that needed services are provided.
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Follow-up post discharge with client/family to ensure client care plan needs/goals are met.
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Develop/review/revise the individual’s plan of care with the client/family
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Consult with client/family/caretaker on advanced directives and educate on client rights and health issues, as needed
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Meet with client and family, inviting any other providers to facilitate needed interpretation services.
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Refer client/family to peer supports, support groups, social services, entitlement programs as needed.
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Identify resources and link client with community supports as needed
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Collaborate/coordinate with community base providers to support effective utilization of services based on client/family need.
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Maintains complete, current and accurate member files which comply with The Health Home Standards. Documents all member related activity in a progress note by the conclusion of the next business day.
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Other duties as requested.
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SKILLS/COMPETENCIES:

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Effective verbal and communication skills
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Ability to teach and influence others
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Demonstrated ability to work effectively in a team environment.
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Demonstrated effective interpersonal relationship and customer services skills
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Good organizational and time management skills
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Ability to work effectively with people from diverse cultures and socioeconomic conditions.
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Actively listens to others to understand their perspective and ensure understanding regardless of barriers.
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Critical thinking ability
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Ability to handle protected health information (PHI) in a manner consistent with The Health Insurance Portability and Accountability Act of 1996.
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Knowledge of computerized systems.
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Knowledge of local and surrounding area resources
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EDUCATION REQUIREMENTS:

Bachelor or master’s degree in a Human Service field and at least three years’ experience working in the human service field OR Must have three years’ experience at Spectrum Health & Human Services as a Care Coordinator I with positive job performance.

EXPERIENCE:

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- “Qualifying Experience” means verifiable full or part-time experience in care coordination with the following populations: person with a chronic illness, and/or persons with a history of mental illness
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Must possess a valid Driver’s License with a satisfactory driving record, and possess a personal vehicle for job requirement
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COMPENSATION: $20.08/hr - $25.60/hr