As part of the Health Homes Program, the Care Coordinator provides services to participants through Care Coordination activities including conducting assessments, care planning, telephone calls, home visits, coordination of benefits and services, linking members to medical providers, specialty medical providers and community-based resources. This position is based in the community approximately 75% of the workweek.
Complete initial and routine Comprehensive Assessments for the purpose of identifying participant care assets, living environment, medical and social support needs
Initiate care planning and implementation of a Comprehensive Care Plan which is participant centered; addressing medical, social, familial and/or behavioral health needs
Engage participants’; routinely telephonically and in-person via home/facility visits to coordinate services, community resources and provide health education
Assess participant’s support service needs and determine eligibility for benefit programs; help securing social, financial and health information
Review and revise Comprehensive Care Plans; focused on chronic disease management, health education, medication adherence and improving health outcomes
Focus on reducing hospital admissions through coordinated care and effective discharge planning with other team members
Collaborate with the participant’s medical, mental health and or specialty care providers, care team members to deliver and coordinate comprehensive quality care and services
Develop and maintain detailed, accurate and timely case records through Health Homes EHR and provider/organization electronic record keeping/database systems as needed
Maintains case records in accordance with Health Home policies/procedures, agency standards and regulatory requirements
Attend team meetings to offer creative solutions and innovative approaches to further enhance the health home model
Bachelor's degree in Social Work or a human services related field with a minimum two (2) years of clinical or case management experience in a medical, long-term care or behavioral healthcare setting
Experience working with the chronically ill, persons with HIV/AIDS, persons with a history of mental illness, substance abuse, homelessness or chemical dependence or equivalent
Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
Computer/typing proficiency to enter/retrieve data in electronic clinical records; experience with email, Internet research, use of online calendars and other software applications
Willingness to travel within New York City 5 boroughs; predominantly, Brooklyn and Queens for home and or provider visits
BILINGUAL; English/Spanish Preferred
Experience working with vulnerable populations with chronic medical, or complex behavioral health needs
2 Years’ experience working with Health Homes, HARP population, knowledgeable/Care Coordination
Diaspora Community Services is an Equal Opportunity Employer!
We offer competitive packages including comprehensive health insurance, 403B, paid holidays, generous PTO, growth potential and a challenging and exciting work environment.
Please submit cover letter with resume and salary requirements.