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Post Date: Apr 15, 2020
Job Type: Full Time
Start Date: May 11, 2020
Salary: 40,000.00 to 45,000.00/Yearly
Location: US - New York - Brooklyn
Job Reference: - n/a -
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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.

Primary Responsibilities:

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

Required Qualifications:

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.