Care Coordinator - ACCESS II Care Coordination Program

800x600 Normal 0 false false false EN-US X-NONE X-NONE MicrosoftInternetExplorer4 TITLE: Care Coordinator DEPARTMENT: ACCESS II Care Coordination Program REPORTS TO: Vice President of Care Coordination Services/Program Director Primary Function: As a Care Coordinator your function is to act as a team leader (overseeing the work of the Patient Navigators) to provide appropriate care coordination services to approximately 80 active clients according to the guidelines set out in the New York City Department of Health and Mental Hygiene and Public Health Solutions Program Guidelines.

Specific Responsibilities:

• Familiarity with the ACCESS II Care Coordination Program Protocol Manual (with particular attention to the specific functions of the Care Coordinator position). This manual was created in accordance with the NYCDOHMH Care Coordination protocol.
• Complete an in-depth screening, intake, and initial assessment; subsequently completing and overseeing a patient-focused care plan, detailed and mutually developed with each participant within 45 days of enrollment.
• Reassess assigned clients every six months to identify new needs and update ongoing needs.
• Implementation of the care plan with documented follow-up and monitoring of the plan at intake every six months after completing reassessment.
• Advocacy and knowledge of available and appropriate services for participants and their families/collaterals.
• Provide accompaniments, referrals, linkage to services, outreach for patient reengagement, and health promotion as needed to meet program monthly goals.
• Conduct home visits as required and as needed (with a minimum of one home visit per service plan period).
• Conduct regular case conferences with outside providers on an as-need basis and quarterly with patients Primary Care Physicians (NOTE: Care Coordinator must ensure that at least one case conference is conducted by the care coordination team at least once per care plan period for every patient).
• Being available for crisis intervention, and provide client assistance services to all clients.
• Remain with a patient until the issue is resolved or addressed.
• Complete accurate and up to date documentation and consents for services in a within the timeframe described in the contracts scope of service.
• Conduct daily morning meetings to address any team issues, delegate the day’s tasks to the Patient Navigators, review the previous day’s activities, and to discuss any patient issues and/or new insights regarding a particular patient.
• Oversee PN documentation of all care coordination activities ensuring accuracy and detail of work.
• Provide weekly one to one supervisions to assigned Patient Navigators.
• Complete yearly performance evaluations for assigned Patient Navigators .
• Conducted quarterly client chart reviews to assigned caseload.
• Participate in yearly quality management trainings and program projects .
• Modified DOT work as needed including performing mDOT services on Saturday’s when it does not conflict with primary duties.
• Be knowledgeable and up-to-date in areas pertaining to HIV/AIDS symptoms and medications.
• Be able to work in and create a positive team environment, manage team members, delegate and oversee team duties, and address team conflicts as they arise.
• Communicate effectively with supervisory personnel in a cooperative and supportive manner.
• Maintain a caseload of 80 patients.

Qualifications:

To perform the job of Care Coordinator successfully an individual must be able to perform each essential duty satisfactorily. The qualifications listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job of Care Coordinator. · A Bachelor’s Degree or higher from an accredited school in an appropriate human/social service and/or public health field · Minimum of one year of direct case management experience* · Knowledge of HIV/AIDS transmission and treatment · Meets physical and cognitive requirements needed to complete assigned tasks and duties of the position with reasonable accommodations being made for individuals with disabilities · Ability to travel within the five boroughs of New York City via public transportation · Ability to demonstrate proper judgment and decision making skills when necessary · Excellent written, verbal, and organizational skills · Ability to manage time effectively · Bilingual in Spanish preferred · Knowledge of computers/word processing a plus