Care Coordinator

3 weeks ago

Jamestown, 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:

  • Delivers core services in accordance with Health Home standards to patients on assigned caseload. Achieves monthly and quarterly productivity expectations.
  • 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 updates 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.
  • 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.
  • 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. Assists patient with transportation needs when necessary to include transportation of the patient when no other means are available.
  • 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 General Assessment with patients eligible to be enrolled and/or enrolled in Health and Recovery Plans (HARP) however are not interested in pursuing these services at this time.
  • 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.

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 two (2) years 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. Sensitivity to cultural diversity, people living with HIV/AIDS and lifestyle and addiction issues essential.

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:

  • Remote hybrid schedules may be available for this position
  • Opportunities for overtime hours may be available for this position
  • 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


  • Spiritual Care Coordinator

    2 weeks ago

    Jamestown, United States Agape Care Group Full time

    Overview: Join Our Team as a Spiritual Care Coordinator (PRN)Are you passionate about making a difference in the lives of others? Do you want to make a meaningful impact and help create positive experiences for patients and families? We are looking for spiritual care coordinators or chaplains to join our team who are committed to guiding each patient with...

  • Care Coordinator

    4 days ago

    Jamestown, Virginia, United States Evergreen Health Services Full time

    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 &...

  • Care Coordinator

    3 weeks ago

    Jamestown, United States Evergreen Health Services Full time

    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 &...

  • Telephonic Care Coordinator

    4 weeks ago

    Jamestown, United States Evergreen Health Full time

    Job DescriptionJob Description Evergreen Health The Telephonic 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...

  • Telephonic Care Coordinator

    3 weeks ago

    Jamestown, United States Evergreen Health Full time

    Job DescriptionJob Description Evergreen Health The Telephonic 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...

  • Health Home Plus Care Coordinator

    4 weeks ago

    Jamestown, United States Evergreen Health Full time

    Job DescriptionJob DescriptionEvergreen HealthThe 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...

  • Health Home Plus Care Coordinator

    2 months ago

    Jamestown, United States Evergreen Health Full time

    Job DescriptionJob DescriptionEvergreen HealthThe 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...

  • Health Home Plus Care Coordinator

    3 weeks ago

    Jamestown, United States Evergreen Health Full time

    Job DescriptionJob DescriptionEvergreen HealthThe 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...

  • Patient Care Coordinator

    1 month ago

    Jamestown, United States F. Smith Strickland DDS, PLLC Full time

    We are looking for enthusiastic individuals that are highly motivated for creating a superb customer service experience.  Patient Care Coordinators are dedicated to improving every aspect of seeking dental care for each patient.  The job includes but is not limited to daily communication with patients concerning scheduling, financial information as well...

  • Quality Incentives Coordinator

    1 month ago

    Jamestown, United States FAMILY HEALTH MEDICAL SERVICES Full time

    Job Type Full-time Description SUMMARY: The Quality Incentives Coordinator will optimize levels of patient care and experiences while maximizing incentives offered by insurance companies for practice growth. Job Title: Quality Incentives Coordinator Reports To: Practice Manager Department: Operations Supervises: N/A Location: Hybrid remote and on-site...

  • Children's Activities Coordinator

    2 months ago

    Jamestown, United States Friends Outside Full time

    Job DescriptionJob DescriptionStep up and be the kind of person who strives to make the world a better place...one individual, one child, one family at a time.This is a Friends Outside contract position at Sierra Conservation Center in Jamestown, CA providing assistance to visitors through the Visitor Center, a sheltered area, which is outside of the...

  • Children's Activities Coordinator

    3 weeks ago

    Jamestown, United States Friends Outside Full time

    Job DescriptionJob DescriptionStep up and be the kind of person who strives to make the world a better place...one individual, one child, one family at a time.This is a Friends Outside contract position at Sierra Conservation Center in Jamestown, CA providing assistance to visitors through the Visitor Center, a sheltered area, which is outside of the...

  • Managed Care Laison

    4 weeks ago

    Jamestown, United States Lutheran Social Services. Full time

    Job DescriptionJob DescriptionMedicaid Managed Care LiaisonRegular Full-TimeWest Seneca, NY, USRequisition ID: 1132ApplyGA Family Services is seeking a Medicaid Managed Care Liaison. Since this position supports both the West Seneca and Jamestown locations, a strong candidate located in Jamestown, NY may be considered.Purpose: All MMCPs must have a Foster...

  • Managed Care Laison

    1 month ago

    Jamestown, United States Lutheran Social Services. Full time

    Job DescriptionJob DescriptionMedicaid Managed Care LiaisonRegular Full-TimeWest Seneca, NY, USRequisition ID: 1132ApplyGA Family Services is seeking a Medicaid Managed Care Liaison. Since this position supports both the West Seneca and Jamestown locations, a strong candidate located in Jamestown, NY may be considered.Purpose: All MMCPs must have a Foster...

  • Managed Care Laison

    3 weeks ago

    Jamestown, United States Lutheran Social Services. Full time

    Job DescriptionJob DescriptionMedicaid Managed Care LiaisonRegular Full-TimeWest Seneca, NY, USRequisition ID: 1132ApplyGA Family Services is seeking a Medicaid Managed Care Liaison. Since this position supports both the West Seneca and Jamestown locations, a strong candidate located in Jamestown, NY may be considered.Purpose: All MMCPs must have a Foster...

  • Operations Coordinator-Payments

    3 weeks ago

    Jamestown, United States First Community Credit Union Full time

    First Community Credit Union is looking to hire a full-time Payments Coordinator to grow and advance your career while assisting our valued members. About FCCU FCCU is the largest credit union in the region with over a billion dollars in assets. We are a growing family of employees who succeed both personally and professionally. We offer competitive total...

  • Staff Development Coordinator LPN

    3 weeks ago

    Jamestown, United States Signature HealthCARE Fentress Co. Full time

    About Us : Signature HealthCARE of Fentress County is a 140-bed skilled nursing facility. We offer superior Clinical, Rehabilitation, Quality of Life programs. Our therapy department offers in-house physical, occupational, speech and restorative therapy services. It is our mission as a family-based organization to revolutionize the healthcare industry...

  • Staff Development Coordinator LPN

    4 weeks ago

    Jamestown, United States Signature HealthCARE Fentress Co. Full time

    About Us : Signature HealthCARE of Fentress County is a 140-bed skilled nursing facility. We offer superior Clinical, Rehabilitation, Quality of Life programs. Our therapy department offers in-house physical, occupational, speech and restorative therapy services. It is our mission as a family-based organization to revolutionize the healthcare industry...

  • Clinical Supervisor

    2 weeks ago

    Jamestown, United States Agape Care Group Full time

    Job Description Overview: Join Our Team as an RN Clinical Supervisor We are looking for impeccable leaders to join our team who are committed to creating meaningful patient experiences. As a clinical supervisor, you'll manage the coordination, supervision, and implementation of professional and supportive services for our hospice patients in a safe,...

  • Care Manager II

    1 month ago

    Jamestown, United States Hillside Family of Agencies Full time

    We have a tremendous opportunity for a Care Manager II to be a lead member of the care team at our Lakewood, NY location. Full time position (40 hours) Monday to Friday. This role would be using principles of assessment, care planning, service and community referrals, and evaluation to coordinate wraparound services using person centered strategies for...