POSITION SUMMARY

Fountain House's Care Management is a Health Home Care Management agency serving individuals living with serious and persistent mental illness. We are the team helping Medicaid recipients to work on person-centered goals and care management to ensure all their medical and psychiatric needs are being met in an efficient and effective manner.

The Care Coordinator is responsible for coordinating health care and ensuring all needs are being met for members in the community who have chronic medical and / or mental health conditions to ensure positive health outcomes, decreased redundancy of care, decreased hospitalizations and secured and sustained social determinants of health such as benefits, food security and housing. The Care Coordinator assists clients in overcoming barriers to quality health care, striving to improve overall health outcomes, reduce avoidable Emergency Room (ER) usage and inpatient hospitalizations. The Care Coordinator is responsible to connect members to appropriate medical services, coordinate care with members' providers and supports, support clients to make well informed choices regarding treatment and provide education & empowerment. The position involves telephonic care coordination, on-site service provision as well as visiting members in the community. Care Coordinators are also responsible for conducting required assessments for health home enrollment and ongoing services.

Shift: Monday - Friday 9AM- 5PM with some flexibility as needed.

Salary: $29.12 per hour, (non-exempt, union role)

ESSENTIAL DUTIES AND RESPONSIBILITIES

Outreach

• Determine member eligibility through ePaces or Medicaid Analytics Performance Portal.
• Actively outreach eligible members through phone, zoom, or in person meetings.
• Give educational presentations to a variety of Fountain House internal programs on care management services.
• Enroll 5 members per month until capacity of 50 members (HARP and non-HARP) is reached. (*subject to change)
• Actively engage caseload in service provision in accordance with care plans.

Enrollment, Health Information Technology, and Documentation

• Maintain documentation for enrollment including the DOH 5055, PSYCKES, Healthix, and withdrawal of consent.
• Enroll member into Relevant (Electronic Health Record, EHR)
• Maintain and update demographics in the electronic health records for each individual served quarterly including upload of eligibility verification
• Document each and every service provided in progress notes entered no later than 48 hours after the encounter
• Conduct State regulated Eligibility Assessments for HARP members in UAS-NY (New York State platform) and complete the Plan of Care for HCBS/CORES referrals within 60 days of enrollment and annually thereafter
• Conduct initial and subsequent periodic needs assessments for care plans at initial enrollment meeting and every 6 months
• Conduct comprehensive assessments within 60 days and annually thereafter
• Complete extensive trainings for, including but not limited to, Relevant EHR, PSYCKES, Medicaid Redesign, HCBS, CORES, Housing, Benefits, MAPP, UAS-NY, and weekly Health Home value add webinars

Member Supports

• Use resources or insurance databases to connect members to quality medical and behavioral health providers and specialists
• Connect members to supports for education, employment, legal, food insecurities, and other community supports
• Apply for and/or maintain benefits such as Medicaid, Food Stamps (SNAP), Social Security, and Social Security Disability
• Secure safe and affordable housing for low income, mental health (HRA 2010e, SPOA), and/or lottery apartments. Complete applications for one shot deals to ensure housing stability when appropriate
• Conduct case conferences with member, their service providers, and any consented supports
• Accompany and support members to and during appointments when follow-up and advocacy is necessary for success
• Assist with transitional care during and after hospitalizations, including but not limited to responding to hospitalization alerts within 48 hours, case conference with hospital and service providers, escort to and from the hospital and follow up appointments, increased reach out and service provision after hospitalization, alert services providers to hospitalization, assist in helping transition back to prior level of care
• Assess safety and conduct safety planning as needed
• Assist members in improving activities of daily living and goal setting, such as budgeting, hygiene, medication compliance, nutrition support
• Assist members in accessing transportation, including obtaining half-fare cards, applying for Medicaid transportation (MAS) and ACCESS-A-RIDE
• Improve health literacy and provide psychoeducation for health conditions
• Assist members in reading and understanding health care materials
• Connect individuals to long term care services, such as managed long term care plans and home health aide services
• Assist members in managing chronic health conditions
• Collaborate with support team including consented family members
• Operate using social practice and relationship building within the care management model

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

• Excellent verbal and written communication skills, including ability to effectively communicate with internal and external care teams
• Excellent interpersonal skills and the ability to engage members effectively
• Excellent computer proficiency (MS Office - Word, Excel, and Outlook)
• Must be able to work under pressure and meet strict deadlines, while maintaining a positive attitude and providing high quality services
• Ability to work independently and to conduct assignments to completion within parameters of instructions given, prescribed routines, and standard accepted practices

REQUIRED AND PREFERRED EDUCATION, EXPERIENCE, AND CREDENTIALS

• Bachelor's Degree required.
• Bilingual, Spanish speaking is a plus.
• 3 years of experience in the mental health field or Health Home Care Management preferred
• Community Health Work certification preferred

Physical Requirements

• To perform this job successfully, an individual must be able to perform each essential duty and meet all physical requirements satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Mission

To create the community innovation and social change needed for people most impacted by mental illness to lead connected and healthy lives.

Vision

Transforming the way the world sees and treats people most impacted by mental illness.

Values

We believe that every person is capable of great things, deserves just and equitable treatment, and the right to self -determination and community.