Evergreen Health

The Health Home Plus Care Coordinator applies the essential activities of case management which include assessment, planning, coordination, monitoring and evaluation with the core components (Comprehensive Case Management, Care Coordination & Health Promotion, Comprehensive Transitional Care, Patient & Family Support and Referral to Community & Social/Support Services) to patients within the Center for Care Coordination. The Health Home Plus Care Coordinator provides care coordination for patients with a diagnosis of Serious Mental Illness (SMI) and/or HIV patients with an unsuppressed viral load that are categorized as high risk, high need. The Health Home Plus Care Coordinator is responsible for the following outcomes: Reduce utilization associated with avoidable and preventable inpatient stays; reduce utilization associated with avoidable emergency room visits; improve outcomes for persons with mental health illness; and improve disease-related care for HIV patients. HH+ Care Coordinators may work with patients enrolled in the Health and Recovery Plans (HARP), to include assessing patients using the HCBS Eligibility Assessment, communication with MCOs regarding Plans of Care, and coordination of referrals to HCBS providers under HARP.

As part of the essential functions of this role, the Health Home Plus Care Coordinator:

• Completes a comprehensive assessment within 60 days of patient’s enrollment and an annual reassessment inclusive of medical, behavioral, social, and rehabilitative needs.

• Completes individualized patient-centered care plan with the patient within 60 days of enrollment and updated monthly to identify patient’s needs and goals, and includes family members and other social supports as appropriate. The Care Plan is also amended annually. HIV HH+ patients require an assessment and care plan amendment biannually.

• Completes and amends patient crisis plan. Coordinates with service providers and health plans as appropriate to secure necessary care during a crisis, share crisis intervention and emergency information.

• Ensures the minimum requirements of four (4) core services, two of which are face to face with the patient, are met for patient engagement in compliance with HH+ program standards.

• Coordinates with multidisciplinary team on patient’s care plan, including but not limited to the primary care physician and/or any specialists involved in the treatment plan.

• Links and refers patients to needed services to support care plan including medical and behavioral health care, patient education, entitlement programs, self-help groups, and recovery and self-management. Attends appointments with patient as necessary.

• Conducts diligent search activities to ensure patient engagement and to assess on-going emerging needs in order to promote continuity of care and improve health outcomes.

• Conducts annual case review with interdisciplinary team to monitor and evaluate patient status.

• Follows up with patient upon notification of ER or inpatient admission and/or discharge and facilities transitions of care within 24-48 hours.

• Advocates for interpretation services and utilizes translation line as needed

• Maintains complete, current, and accurate patient charts that comply with the Health Home Standards.

• Documents all patient-related encounters and chart activities in a progress note within 24-48 hours, including encounters with patient, providers, and other members of the care team. Attempted contacts and completion of documentation (such as the assessment and care plan) must also be documented in the form of a progress note.

• If applicable, completes the Eligibility Assessment with patients enrolled in Health and Recovery Plans (HARP).

• If applicable, enters data collected from the Eligibility Assessment into the NYS Health Commerce System. Submits the results of the Eligibility Assessment to MCOs for approval and service determination.

• If applicable, completes the HARP Health Plan Summary with HARP enrolled patients, communicates with MCOs and Home and Community Based Services (HCBS) providers to ensure referral and linkage to services outlined in the Health Plan Summary.

• Enters data timely and accurately to promote patient care delivery and participates in ongoing QI/QA activities and training to improve patient experience and increase data quality where needed. Maintains and protects sensitive information in enterprise systems and uses/shares data in compliance with Information Governance and Security Policies.

  Qualified Candidate will have a Bachelor’s Degree in social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or another human services field. Bachelor's degree with a CASAC preferred. With two (2) years of qualifying experience working with people living with Serious Mental Illness (SMI) and Substance Use Disorders (SUD) or people living with HIV. -OR- A Masters of Social work, Mental Health Counseling, Psychology, or another related field. Current NYS License (LMSW, LMHC, LCSW) preferred. With one (1) year of qualifying experience working with people living with Serious Mental Illness (SMI) and Substance Use Disorders (SUD) or people living with HIV.

  Qualifying experience means post-graduate experience providing direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or linking individuals with Serious Mental Illness, developmental disabilities, or substance use disorders to a broad range of services essential to successful living in a community setting. Must possess a valid NYS Driver’s License and an insured, dependable car to use for client service activities, including transporting clients when necessary. Sensitivity to people living with HIV/AIDS and lifestyle issues is essential.

  Job Type: Full-time

  Required education: Master’s (plus 1 year experience) (LMSW, LMHC, LCSW preferred); OR Bachelor’s (plus 2 years experience) (CASAC preferred)

  Required experience: Working directly with people living with Severe Mental Illness (SMI) and Substance Use Disorder (SUD) or people Living with HIV.

  Additional requirements: Valid NYS driver’s license and insured, dependable car

  What Evergreen Health Offers You:

• Multiple comprehensive medical health insurance plans for you to choose from

• Dental and Vision coverage at no cost to you

• Paid Time Off package that equals 4 weeks of time in your first year

• 403b with a generous company match

• Paid parking or monthly metro pass

• Professional development opportunities

• Paid lunch breaks