Under the supervision of the Care Management Supervisor, the Complex Care Coordinator manages a panel of patients diagnosed with serious behavioral health (mental health, substance use disorder, alcoholism) and HIV conditions, and complex socio-economic needs. The Complex Care Coordinator's primary goals are to increase patient connection to behavioral health, primary care, pharmacy support, and social services; reduce avoidable emergency department and inpatient utilization; and improve patient wellness and health outcomes.
SUMMARY OF DUTIES AND RESPONSIBILITIES
Consents patients into appropriate care management program (e.g., Health Home, Non-Medicaid, etc.); utilize motivational interviewing to complete intake or yearly assessment; and develop longitudinal care plan with an emphasis on increasing self-management and harm reduction.
1) Completes all specialized patient evaluations (e.g., Health and Recovery Plan) and documentation in specific systems (e.g., CARES, UAS-NY).
2) Works in the community to connects patients to a variety of clinical and support services including but not limited to behavioral health, medical services, pharmacy, social, legal, public assistance, transportation, housing services, etc.
3) Provides care management services in hospitals, health centers, and various community-based settings. Provides a minimum of two core services (or three documented attempts) per month with a minimum of one face-to-face (FTF) engagement quarterly, for each assigned patient. Adheres to intensified monthly core services and face-to-face engagement thresholds established for each sub-program (e.g., Health Home Plus (4 core services / 2 FTF), AOT (4 core services / 4 FTF), NYC Department of Health & Mental Hygiene (DoHMH) Grant (2 core services / 2 FTF).
4) Convenes case conferences (every six months at minimum), ensuring each patient's care team is up to date on patient's status and needs. Responds promptly to all care team member inquiries and ensure that all discussions are documented in the electronic medical record (EMR). Prioritizes case conferences for any patient exhibiting signs and symptoms of behavioral health crisis or relapse to use of substances or alcohol.
5) Maintains expertise in approved techniques for de-escalation, crisis management, and safety planning to effectively monitor and support patients in managing triggers, coping with stressors, and seeking crisis support. Proactively develops safety plans for all enrolled patients and updates them at least annually.
6) Monitors and responds to critical alerts (e.g., inpatient hospital and emergency department admission / discharge, arrest/incarceration, etc.) in accordance with all related policies for supporting transitions of care.
7) Utilizes a directory of service providers to support connection of patients to medical, behavioral health, social support, wellness and family support services, in support of meeting care plan goals and interventions.
8) Develops and maintains proficiency in the EMR. Proactively manages daily schedule to balance travel time, appointment duration, and ensure documentation of all work completed daily.
9) Demonstrates integrity, compassion, accountability, respect and excellence in all interactions with leaders, colleagues, patients and community stakeholders.
10) Adheres to all operating policies, procedures and requirements as defined and subject to change by all applicable federal, state, local, and corporate requirements.
11) Performs other duties as assigned.
QUALIFICATIONS FOR THE JOB: CERTIFICATION(S)/LICENSE(S):
Preferred: New York State CASAC (Credentialed Alcoholism & Substance Abuse Counselor), Licensed Clinical Social Worker
YEARS OF EXPERIENCE
Minimum of 2 years' experience supporting chronically ill populations, managing significant behavioral health and psychosocial needs.
COMPUTER PROGRAMS/SOFTWARE OPERATED
- Microsoft Office Suite (Outlook, Word, Excel)
- Epic Electronic Medical Record (EMR) System
- Various online data portals/systems, e.g., PSYCKES
