HEALTH HOME CARE COORDINATOR

SUMMARY/OBJECTIVE:

Heath Home Care Coordinators work closely with clients on a one-on-one basis to provide guidance, support, and advocacy to clients dealing with chronic conditions to include mental health, substance use and medical issues. Their function is to help their clients navigate complex systems, by linking and connecting community resources to remain successful and independent while decrease emergency room and inpatient hospitalizations.

Essential Functions (Job Duties)

• Interviewing/Screening referrals as assigned by the Program Supervisor/Team Lead
• Assessing program eligibility and client needs
• Providing emergency and/or interim services including referral and linkage for incoming and returning consumers
• Attending and participating in the monthly Single Point of Access (SPOA) meetings; including being prepared to present on referrals and review rostered individuals on the waiting list
• Completing required assessments per agency, Lead Health Home, DOH and OMH
• Assisting active Health Home clients with the development of their care coordination service plans.
• Evaluating client progress and outcomes of interventions
• Completing daily progress notes concurrently and/or within 72 hours, documenting information related to activities undertaken on behalf of the client related to the goals indicated on the service plan
• Maintaining a professional and responsible manner in relation to clients, staff and the public
• Adhering to professional standards and the code of ethics of the respective clinical discipline
• Maintaining confidentiality in accordance with HIPPA regulations as it pertains to the clients served by the program
• Engaging active clients towards the goal of their own rehabilitation and recovery
• Linking clients with appropriate services
• Advocating for clients’ access to services and for the best interest of the clients
• Transporting clients as needed, linking and connecting to public resources for independent transportation
• Assisting and coordinating crisis intervention services to active clients in collaboration, if necessary, with the local mental health center
• Assisting clients and providing interventions in order to help them reach their goals and improve their quality of life
• Monitoring clients’ situations and overall well-being
• Consulting with collaterals, with the client’s permission, towards improving client outcomes while assisting them in addressing their goals
• Taking the lead role when collaborating with other service providers towards a coordinated effort to ensure continuity of care for the clients
• Preparing and maintaining client records in accordance with departmental procedures
• Developing, as needed, other services to meet client needs when no appropriate service exists or when existing services are inadequate
• Planning for the use of client service dollars in conjunction with the service plan and as related to the client’s goals.
  • Maintaining and reconciling the allocated emergency/client specific petty cash fund
  • Utilizing the purchase order and check request process to request the use of client specific funds
• Maintaining client service utilizing Electronic Health Record (EHR)
• Attending and participating in individual, group and team meeting
• Assisting with client coverage for other staff in their absence and arranging for such in yours
• Reporting to Supervisor, Program Manager and/or Director for all emergencies and other concerns and work towards resolution
• Adhering to agency policies and procedures
• Adhering to Lead Health Home policies and procedures

Competencies

• Excellent oral and written skills
• Ability to articulate clearly to clients
• Ability to work in a fast-paced environment working on multiple tasks throughout the day
• Stress Management
• Confidentiality
• Ability to navigate multisystem

Position Type/Expected Hours of Work

This is a full-time/part time position.
Workweek schedule: Monday through Friday.
Hours of work: Discuss with Manager

Hours and schedules may vary depending on Company need and workload as well as client needs. Employees will be given as much advance notice as possible when such changes occur.

Travel

Area of coverage: North Country Region
(Franklin County, Portions of: Essex, Clinton and St. Lawrence Counties)

Required Education and Experience

• Bachelor’s degree in one of the qualifying fields and two (2) years of Experience; OR
• A NYS teacher’s certification for which a bachelor’s degree is required, OR
• A Bachelor’s level education or higher in any field with five (5) years of experience working directly with persons with behavioral health diagnosis; OR
• A Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and two (2) years of Experience

Experience must consist of:

• Providing direct services to people with Serious Mental Illness (SMI), Developmental Disabilities, Alcoholism or Substance Abuse, and/or children with Severe Emotional Disturbance (SED); OR
• Linking individuals with Serious Mental Illness, children with SED, Developmental Disabilities, and/or Alcoholism or Substance Abuse to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services).

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
Employment at Citizen Advocates is “at will”. You are free to resign at any time and for any reason sufficient to you, just as Citizen Advocates is free to terminate your employment at any time and for any reason. We do not guarantee continued or permanent employment.