Job Abstract

Conducts assessments and develops client/member centered plans of care. Provides coordination of services between the varying providers for clients / members with complex psychiatric, substance use, and/or co-morbid medical conditions. Ensures access and linkage to the full array of necessary physical and behavioral health services and other community based services to address social determinants of health. Coordinates effective communication between all providers for the ultimate benefit of the client/member. Works under general direction.

$23.17 - $28.96 Hourly

What You Will Do

• Utilizes approved assessments to identify clients/members needs and develop initial and ongoing clinical plan of care.
• Updates plan at specified intervals, and as needed based on changes in client/member condition or circumstances.
• Performs and maintains effective care management for assigned caseload of clients/members. Tracks and monitors progress; maintains detailed, accurate and timely progress notes and other documentation.
• Develops inventory of resources that meet the clients/members needs as identified in the assessment.
• Provides linkage, coordination with, referral to and follow-up with appropriate service providers and managed care plans. Facilitates periodic case record reviews and case conferences with all providers serving the clients/members.
• Works collaboratively with team members to provide outreach for and engage resistant/hard to reach clients/members to accept program services.
• Provides information and assistance through advocacy and education to clients/members and family on availability and eligibility of entitlements and community services. Arranges transportation and accompanies clients/members to appointments as necessary.
• Participates in initial and ongoing trainings as necessary to maintain and enhance care management skills.
• Maintains updated case records in program EMR. Maintains case records in accordance with program policies/procedures, VNS Health standards and regulatory requirements.
• Participates and consults with team supervisor in case conferences, staff meetings, and discharge planning meetings to determine if client/member requires an alternate level of care or is appropriate for discharge.
• FOR Recovery Coordination Agencies (RCA) and State Designated Entities (SDE) programs:
• Conducts in-person visits to perform NYS eligibility assessments to determine Tier 1 or 2 eligibility for HCBS service. Works with clients/members, Peer Specialist, Supervisor and MCOs to develop Initial and Ongoing Plan of Care (PoC) and request necessary approvals and authorizations as needed.
• Participates in initial and ongoing trainings as necessary to maintain current knowledge of Health Home, HARP HCBS and DOH processes.
• Maintains knowledge of the service providers in the HCBS, MCO and health home network if applicable. Provides overarching service coordination between clients/members, SDE/RCA, HCBS service provider and MCOs.
• FOR Health Home programs:
• Maintains appropriate documentation and standards for all specialized caseloads such as HH+, AOT, Non Medicaid, HARP cases and other special populations.
• For Children’s Health Home:
• Completes the Child and Adolescent Needs and Strengths New York (CANS) assessment to determine acuity and to develop initial and ongoing Plan of Care documents.
• Consults with management and provides reports of suspected abuse and neglect when there is reasonable cause to suspect that a child is a victim of child abuse/neglect.
• Provides support to legal parent/guardian addressing specific needs relevant to care management of children/adolescents.
• Maintains appropriate documentation and standards for all specialized caseloads such as waiver transition Home and Community Based Services (HCBS) and other special populations.
• FOR Critical Time Intervention (CTI):
• Utilizes approved CTI assessments to prepare initial and ongoing clinical and psychosocial evaluations of mental health, health and other related service needs of identified patients. Confirms acuity level of identified patient and tailors service plan accordingly, reassessing as needed.
• Establishes CTI patient relationship (pre-CTI) while patient is still in hospital and performs at least one pre-CTI visit; schedules first post-discharge visit prior to discharge. Makes home visits thereafter.
• Identifies appropriate staff/family support for hand-off during last six weeks of Phase 2 (four – six months of engagement). Meets with Health Home manager/staff to facilitate warm hand-off of each patient Phase 3 care/services; conducts a telephone call at the end of Phase 3 for each patient to review patient's progress toward goals and determine whether additional follow-up is required.
• Participates in special projects and performs other duties as assigned.

Licenses and Certifications:

• Valid NYS ID or NYS driver’s license required. NYS Community Mental Health Assessment instrument and HCBS training completion preferred
• Must complete necessary training to administer NYS Eligibility Assessment for HCBS service in the UAS system within 60 days of start date.
• Child and Adolescent Needs and Strengths New York (CANS) certification preferred
• Must complete necessary training to administer the CANS NY assessment in the UAS system within 60 days of start date.

Education:

• Bachelor's Degree in a human services or related field required
• Enrollment/attendance in Master’s degree program in human services or related field preferred

Work Experience:

• Minimum of two years of experience providing direct services to clients/members with Serious Mental Illness (SMI), developmental disabilities, substance use disorders and/or chronic medical conditions client required with a Bachelor’s degree; minimum of one year of experience with a Master’s degree.
• Effective oral/written/interpersonal communication skills required
• Bilingual skills may be required as determined by operational needs.
• Basic computer skills required