Care Coordinator, HARP Program

• Gather information for intake, assessment, and reassessments.
• Provide care management and support to a caseload through the coordination of medical, mental health, HCBS and substance use services.
• Conduct assessments and prepare a comprehensive plan of care as directed by NY State and Managed Care Organizations.
• Collaborate with the individual's HARP team including: MCOs, HCBS providers, as well as other medical and treatment providers.
• Generating referrals to providers, community-based resources, and appropriate services and other resources to assist in goal achievement.
• Ensure entitlements, insurance, and benefits are in place and maintained.
• Develop service plans and resolve barriers to effective service utilization.
• Monitor member’s progress in utilizing services (appointments, treatment, medication, etc.) through telephonic and direct contact.
• Attend and prepare for Interdisciplinary Care Team meetings which will feature newly enrolled, frequently admitted, high utilizing at risk members.
• Accompany members to/from any appointments when needed.
• Documents in a comprehensive manner to ensure that all goals, interventions, and care coordination activities for each member in EMR system, and other applicable software programs, are compliant with professional standards and regulatory guidelines.
• Educate members on health-related conditions and support members in addressing gaps in health care through connection to direct care providers, resources and medications, as appropriate to members conditions.
• Assist in crisis intervention and provide or refer to crisis services.
• Extensive fieldwork required, including home visits and community work such as visiting hospitals and emergency rooms when determined necessary.
• Ensure that members follow-up with aftercare discharge (i.e. fill prescriptions, make appointments).
• Assists with maintaining quality, preparing for audit revies, and quality improvement projects.
• Attend regularly supervision, staff meetings and relevant training as required.
• Bachelor’s Degree Required in one of the following fields: Social Work, Psychology, Education, Rehabilitation, Occupational Therapy, Counseling, Community Mental Health, Sociology, Physical or Recreational therapy. Degrees in other related areas may be considered.
• For bachelor’s level candidates, two (2) years OR for master’s level candidates, one (1) year of related experience working with individuals with severe mental illness.
• Ability and willingness to regularly travel with members, in some instances to many locations using various modes of reliable and safe transportation.
• You must have excellent interpersonal and time management skills.
• Proficiency in email and documentation on electronic platforms.
• Comfortable with fieldwork and navigating social services systems.
• Working knowledge of NY State Health Home System and Plan of Care process.
• Case Management Experience within the Integrated Collaborative Care Model Approach.
• Previous history of conducting discharge planning and providing direct education around medical conditions.
• Knowledge of Psyckes, E-Paces, HCS (UAS) MAPP, Microsoft Teams Video knowledge preferred.
• Strong interpersonal and assessment skills, the ability to remain calm and poised with challenging members who often present as in a constant state of crisis.
• Experience with chronic condition management, particularly Diabetes, HIV, Heart Disease.
• Ability to multi-task and work under multiple priorities and deadlines in a fast-paced environment.
• Computer literacy: Proficiency with Word and Excel.

Essen Health care is proud to be an equal opportunity employer, and we seek candidates who desire to work in and serve an ethnically diverse population.