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. 

The Intensive Care Coordinator (ICC) provides assessment, care planning, and service coordinationactivities for eligible clients, following a caseload ratio as defined by the Health Home, NYSDOH or department for a given target population. The ICC works closely with medical, behavioral health and social service providers to manage identified needs, stabilize participants and reduce healthcare costs and align services that promote access to care and enhanced health outcomes for all clients.

• Monitor progress of each client on an ongoing basis through delivery of face to face, escort, written, electronic and telephonic outreach/monitoring/collaboration and planning activities, in accordance with Health Home, DOH, and departmental guidelines.

• Provide services to clients as needed to meet Care Plan objectives, including facilitating referrals to medical, behavioral health and social assistance entities; assisting with management of entitlements (Medicaid, SNAP benefits, SSI, etc.); assisting with securing stable housing; and arranging transportation and other services to support wellness and health care compliance

• 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.

• 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.

• 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 time frame outlined in the Program Manual guidelines.

• 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.

• Promptly review and address 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.

• Others duties as assigned by NADAP management.

• Bachelor’s Degree in Social Work, Human Services or related field required

• Minimum of three (3) years 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

• Experience working with participants with severe mental illness, required

• 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 required
  

All your information will be kept confidential according to EEO guidelines.