Care Coordinator

6 days ago

Buffalo, United States Evergreen Health Full time
Job DescriptionJob Description

Evergreen Health


The 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). The Care Coordinator will be 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/or substance use disorders; and improve disease-related care for chronic conditions.

As part of the Essential Functions for this role, the Care Coordinator:

  • Completes a comprehensive health assessment/reassessment inclusive of medical/behavioral/rehabilitative and long term care and social service needs .
  • Consults with multidisciplinary team on client’s care plan/needs/goals .
  • Conducts outreach and engagement activities to assess on-going emerging needs and to promote continuity of care and improved health outcomes .
  • Consults with 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, behavioral health , patient education, and entitlement programs.
  • Follows up with patient upon notifications of ER or inpatient admission and or/ discharge and facilities transitions of care within 24-48 hours.
  • Advocate for interpretation services and utilizes translation lines as needed .
  • 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 .
  • Prepare clients crisis interventions plan and coordinates with services providers and health plans as appropriate to secure necessary care, share crisis intervention and emergency information .

Qualified Candidate will have a Bachelor’s degree in health, human or education services and one year of qualifying* experience or Associate’s degree in health, human or education services and one (1) year of qualifying* experience. Qualifying* experience equals professional case management or care coordination experience with the following populations: persons with a chronic illness, and/or persons with a history of mental illness, homelessness, or chemical dependence. Candidate must have a valid NYS Driver’s License and an insured, dependable car.

Job Type: Full-time

Required education: Bachelor’s (plus 1 year experience); Associates (plus 2 years experience)

Required experience: Care Coordination/Case Management; Working with clients experiencing chronic illness, homelessness, mental illness and/or chemical dependence

Additional requirements: Must have dependable, insured vehicle and NYS Driver’s License


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

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