Provide comprehensive care management, care coordination, and health promotion to Medicaid enrolled persons with the goal of reducing unnecessary hospitalizations, decreasing emergency room visits, and improving health outcomes.
Observe and abide by HIPAA and the HIV Confidentiality Law.
Conduct intakes, comprehensive health assessments, and reassessments to identify health care, mental health, chemical dependency and social service needs.
Develop comprehensive, measurable, goal-oriented care plans in collaboration with an interdisciplinary team of external and internal providers. Maintain regular contact with interdisciplinary team of Health Home at Risk network providers identified in client's care plan. Act as team leader for the client's care coordination activities, and conduct case conferences on a regular basis.
Refer clients to services including but not limited to mental health and substance abuse treatment, entitlements and housing. Advocate for and assist clients in accessing and maintaining these services. Provide crisis intervention, and updates on the client's crisis situation to the interdisciplinary team. Conduct home and field visits as needed.
Track patient medical appointments, labs and, other activities required to maintain the client's health. Utilize health information technology, as applicable, to coordinate care. Coordinate all hospital discharges with hospital or acute care providers, and follow-up on recommendations from the ER, hospital, or acute care facility.
Provide referrals, for appropriate services for family members and collaterals in conjunction with client’s care plan.
Provide information to clients about disease management, medications and treatment adherence, psychosocial issues and harm reduction education.
Incorporate the Transtheoretical Model of Behavior Change, as applicable.
Bachelor's Degree in Social Work, Human Services or related discipline with two years’ experience working with persons with chronic medical conditions, HIV/AIDS, mental illness, homelessness, chemical dependency, and/or other populations of persons in need.
Ability to work as a member of a team, delegating and coordinating efforts within Health Home provider network. Ability to provide strength-based, client-centered, proactive care management.
Strong computer skills. Experience working with electronic medical records and/or health information exchanges (e.g. HIXNY) preferred.
Strong communication (verbal, written, and active listening) skills.
Attention to detail, strong organizational and time management skills.
Must have a valid, unrestricted driver's license and independent means of transportation for frequent travel.