Senior Care Coordinator
Job Summary:
The Senior Care Coordinator provides case management services for an assigned case load of members which includes the following:
- Maintain a caseload of about 40 – 45 clients which includes a minimum of one monthly client contact as well as one monthly provider/HCBS/MCO/family contact. Additional contact may be necessary and is at the discretion of management.
- Willing to make home visits to clients in potentially undesirable locations in various home environments.
- Successfully complete the HARP Assessment training in the Uniform Assessment System for New York (UAS-NY). Performs HARPs assessments/reassessments; maintains an active Health Commerce System (HCS) account.
- Promote a team approach within the Care Coordination Department.
- Interviews clients to assess client needs, prioritize needs, identify barriers in addressing needs, and strategize to overcome barriers.
- Assist clients in the development of the care plan, self-management goals and strategies; documents them in the Electronic Medical Record (EMR).
- Assist client with coordination of appointments including but not limited to scheduling, rescheduling, providing appointment reminders and arraigning transportation.
- Works closely with the interdisciplinary care team including PCP, psychiatrist, therapist, residential services, substance abuse treatment program, etc.
- Develops interdisciplinary care plan and other case management tools by participating in meetings; coordinating information and care requirements with other care providers; resolving issues that could affect smooth care progression; encouraging peer support; providing education to others regarding the care management process.
- Monitors the delivery of HCBS services to ensure clients are following through with goals identified in their care plans.
- Attend clinical meetings to review clients’ utilization of services.
- Complete treatment record reviews.
- Updated HARP Plan of Care once notice of decisions are received, final approval, every 6 months or if a significant change has taken place.
- Maintains a daily/monthly log of contacts for billing purposes.
- Completes progress notes daily and ensure they are documented properly on services log and in our EMR.
- Completes other required paper work such as mental health and drug court reports, consents, etc.
- Respects clients by recognizing their rights; maintaining confidentiality.
- Maintains quality service by establishing and enforcing agency standards.
- Maintains client care database by entering new information as it becomes available; verifying findings and reports; backing up data.
- Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; benchmarking state-of-the-art practices; participating in professional societies.
- Conducts home visits and participates in client appointments and case conferences in the community with other providers.
- Researches community resources and government benefit programs to determine eligibility criteria, provide appropriate referrals, and perform follow up activities for referrals.
- Outreaches to clients to facilitate keeping scheduled appointments; arranges for metabolic and periodic preventive screening, per evidence based guideline standards and review results with clients and their family.
- Coordinates services between clients and extended care team providers to ensure that integrated care plan is fully implemented.
- Regularly reviews patient information from care team members to identify patients requiring outreach and engagement.
- Assist clients in identifying the necessary skills to promote self-sufficiency, medical adherence, and the ability to access and maintain community resources on their own.
- Reassess clients annually by completing the Health Home Comprehensive Assessment located in our EMR system.
- Utilizing MAPP, Healthelink, EPACES, GSI, Cerner, or any other identified programs or EMRs
- Other duties, as assigned by supervisor
Education:
- A Bachelor's degree in any of the following: Child & Family studies, Community Mental Health, Counseling, Education, Nursing, Occupational Therapy, Physical Therapy, Psychology, Recreation, Recreation Therapy, Rehabilitation, Social work, Sociology, or Speech and Hearing; OR
- NYS licensure and current registration as a Registered Nurse and a Bachelor's degree; OR
- A Bachelor's level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses; OR
- A credentialed Alcoholism and Substance Abuse Counselor (CASAC).
Skills:
- Excellent written and verbal communication skills
- Proficient in Microsoft Word, Microsoft Excel and Microsoft Outlook.
- Ability to utilize current technology including smart phones, surface tablets, laptops, Wi-Fi and connecting and maintaining connection on a secure network.
- Ability to manage time efficiently.
Experience:
- Four years of experience (a Master's degree in a related field may substitute for one year's experience) either:
- Providing direct services to persons diagnosed with mental disabilities, developmental disabilities, alcoholism, or substance abuse, OR
- Linking persons who have been diagnosed with mental disabilities, developmental disabilities, alcoholism or substance abuse to abroad range of services essential to successfully living in a community setting.
Training and Supervision:
- Specific training for the designated assessments tool(s), the array of services and supports available, and the client-centered service planning process. Training in assessment of individuals whose condition may trigger a need for HCBS and supports, and an ongoing knowledge of current best practices to improve health and quality of life.
- Supervision from a licensed level clinician with prior experience in a behavioral health clinic or case management supervisory capacity.
- Strong clinical knowledge in subject area and the impact of mental health, substance use disorders and psychosocial stressors on physical health conditions.
- Knowledge of CMS and or NYSDOH regulations governing medical management in managed care
- Demonstrated professional writing and electronic documentation along with clear and concise assessment skills.
- Use of computer software --Microsoft Office Suite including Word and Outlook calendaring, and Excel.
Miscellaneous :
- Vehicle must be free and clear of any business or personal advertisements.
- Must possess a clean NYS Driver’s License and have reliable transportation.
Location:
1000 Young Street, Tonawanda, NY with traveling in the Erie County Area
Position Hours:
Monday - Friday 8:00a.m. - 5:00p.m.
Why work at Horizon?
- Summer Hours
- Anniversary and Life Event Bonuses
- Benefits and Wellness Program
- Employee Appreciation Events
- Growth and Educational Training Opportunities
- 401k Match and Profit Sharing Programs
- Employee Referral Bonuses