NADAP’s Health Home Care Coordination program works in partnership with medical and behavioral health providers to align services that promote access to care and enhanced health outcomes for Medicaid recipients with a history or risk of over-utilizing medical and behavioral health services. Using an integrated medical-behavioral health approach, our team conducts face to face and telephonic outreach, provides assessment, intervention, referral, linkage, monitoring and service planning for individuals with complex medical conditions, severe mental illness, substance abuse and long-term care needs. Care Coordinators work closely with networks of clinical service providers to manage identified needs, stabilize participants and reduce health care costs.
NADAP, Inc. is seeking a Care Coordinator for our Health Homes program to coordinate medical, mental health and substance abuse services for Medicaid recipients. Using an integrated medical and behavioral health home approach involving fieldwork and telephonic contact, our Health Home Care Coordination service conducts outreach, assessment and service planning to coordinate care for participants who have severe and persistent mental illness and/or chronic medical conditions. Care Coordination staff work closely with clinical service providers and deliver interventions to manage participants’ medical and behavioral health services. Care coordination helps participants access and effectively use clinical services to achieve better health care outcomes while containing costs.
- Complete client centered comprehensive functional assessments to identify the medical, behavioral health, and social needs/goals of each client.
- Develop, review, and update written/electronic person centered care plans that are driven by functional assessment outcomes and shared with and developed/updated in partnership with the client and his/her Health Home network partners and collateral supports. Ensure that all Care Plans uphold the policy and procedure set forth by the department and Health Home.
- Utilize Electronic Health/Medical Record system(s) of assigned Health Home and NADAP database tools to maintain documentation and all relevant treatment records, entering contact notes within the timeframe outlined in the Program Manual guidelines
- Facilitate referrals (securing appointment date/time/location) to network medical, behavioral health and social assistance entities as needed to meet Care Plan objectives.
- Maintain an accurate caseload panel through prompt identification and response to cases appropriate for level of care changes including but not limited to discharge or transfer activities.
- Maintain collaborative relationships with all service providers utilized in the care planning interventions, sharing/extracting regular status updates and participating in case conferences as needed (and as outlined in the policy and procedure of the department and lead Health Home providers) to monitor level of care and health status for all members.
- Promptly review and address treatment/medication adherence issues/concerns and any crisis situations that arise for any client with supervisory staff, service network and any involved legal entities.
- Develops, adheres to, and documents daily schedule of appointments; informs supervisor of scheduling conflicts or changes and maintains accurate record of daily activities.
- Participate in individual and group supervision as scheduled by the appointed supervisor.
- Performs other job related duties as assigned.
- Bachelor’s Degree in Social Work, Human Services or related field required
- Minimum of one (1) year of job-related experience providing medical, mental health or substance abuse-focused care coordination services to individuals with chronic medical conditions or severe and persistent mental illness
- Working knowledge of health care environments, clinical terminology and health information systems strongly preferred
- Excellent interpersonal, organizational, writing and computer skills
- Experience in care coordination for individuals with chronic medical and complex behavioral health conditions
- Ability to travel within Manhattan, Queens, Brooklyn and Bronx with NYC public transportation
- Bilingual Spanish/English