Coordinating Manager - Level B (Enrollment Specialist)

NYC Health + HospitalsCommunity Care reaches outside the walls of our hospitals and brings health care to patients where they live. With more than 600 dedicated employees, Community Care provides services including home care, community care coordination, and community-based care management to individuals managing chronic health conditions residing in Brooklyn, Manhattan, Queens and The Bronx. At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.Job DescriptionPURPOSE OF POSITION:Under the supervision of the Director of Care Coordination, Central Support Team, the Care Coordinator is responsible for managing a panel of patients diagnosed with serious behavioral health conditions (including mental health, substance use disorder, and alcoholism), HIV, and complex socio-economic needs. The primary goals of the Complex Care Coordinator are to enhance patient engagement with behavioral health services, primary care, pharmacy support, and social services; reduce unnecessary emergency department visits and inpatient admissions; improve overall patient wellness and health outcomes; and enroll patients in different communities and hospital facilities to increase the organization's census.Duties & ResponsibilitiesAREAS OF RESPONSIBILITIES:Obtaining consent and facilitating enrollment across various communities and hospital facilities.SUMMARY OF DUTIES AND RESPONSIBILITIES:1) 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, including enrolling patients in different communities and hospital facilities to increase the organization's census.2) Completes all specialized patient evaluations (e.g., Health and Recovery Plan) and documentation in specific systems (e.g., CARES, UAS-NY).3) 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.4) 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).5) 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.6) 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.7) Monitors and responds to critical alerts (e.g., inpatient hospital and emergency department admission discharge, arrestincarceration, etc.) in accordance with all related policies for supporting transitions of care.8) 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.9) 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.10) Demonstrates integrity, compassion, accountability, respect and excellence in all interactions with leaders, colleagues, patients and community stakeholders.11) Adheres to all operating policies, procedures and requirements as defined and subject to change by all applicable federal, state, local, and corporate requirements.12) Performs other duties as assigned.Minimum QualificationsEDUCATIONAL LEVEL:Required: Bachelor's degree in human services field (e.g. social work, nursing, psychology, etc.) QUALIFICATIONS FOR THE JOB:CERTIFICATION(S)LICENSE(S):Preferred: New York State CASAC (Credentialed Alcoholism & Substance Abuse Counselor), Licensed Clinical Social WorkerKNOWLEDGEABLE IN:Field Work and working in multiple boroughs Bronx & QueensEQUIPMENTMACHINES OPERATED:PrinterScannerCopierFax machine, LaptopTabletCOMPUTER PROGRAMSSOFTWARE OPERATED:ProficiencyExperience in the following:•Microsoft Office Suite (Outlook, Word, Excel)•Epic Electronic Medical Record (EMR) System•Various on line data portalssystems, e.g., PSYCKEDepartment PreferencesYEARS OF EXPERIENCE:Minimum of 2 year's experience supporting chronically ill populations, managing significant behavioral health and psychosocial needs (1 year with master's degree)If you wish to apply for this position, please apply online by clicking the "Apply for Job" button or forward your resume to noting the above Job ID # 116423.NYC Health and Hospitals offers a competitive benefits package that includes:Comprehensive Health Benefits for employees hired to work 20+ hrs. per weekRetirement Savings and Pension PlansLoan Forgiveness Programs for eligible employeesPaid Holidays and Vacation in accordance with employees' Collectively bargained contractsCollege tuition discounts and professional development opportunitiesMultiple employee discounts programs

Created: 2025-01-16