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 coordination 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 for members in the community who have chronic medical and / or mental health conditions. 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, visiting members in the community, and conducting required assessments for health home enrollment and ongoing services.
ESSENTIAL DUTIES AND RESPONSIBILITIES
• Conduct member outreach and engagement activities to designated and potential Health Home members, including face-to-face, mail, electronic, video conferencing and telephone contact.
• Maintain a caseload of up to 50 HARP and non-HARP members (subject to change).
• Conduct initial and subsequent periodic needs assessments.
• Assist in the development and execution of member’s goals.
• Develop comprehensive plans of care based on assessments and identified needs and goals.
• Assist members with accessing health care and social services systems, community-based resources, and the coordination of these services.
• Ensure individual’s needs are met by way of housing, food security, and entitlements.
• Deliver quality support services that meet or exceed health home standards of care.
• Use health information technology/electronic health record platforms to link services, document contacts and assessments, and communicate amongst care management team, providers, and members.
• Complete various trainings needed, including but not limited to trainings on the Care Management Model, Home and Community Based Services and the New York State Eligibility Assessment.
• Work collaboratively with Fountain House clubhouse, housing and Home and Community Based Services (HCBS) teams as well as outside agencies support services teams.
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.