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Complex Care Coordination Manager
2 months ago
About NYC Health + Hospitals
NYC Health + Hospitals/At Home extends healthcare services beyond traditional settings, delivering care directly to patients in their communities. With a dedicated workforce, Community Care offers essential services such as home care, community care coordination, and management for individuals facing chronic health challenges across various boroughs.
Our mission at NYC Health + Hospitals is to provide exceptional healthcare services to all individuals, ensuring a person-centered approach that embodies our ICARE values: Integrity, Compassion, Accountability, Respect, and Excellence.
Position Overview
ROLE OBJECTIVE
Under the guidance of the Care Management Supervisor, the Complex Care Coordinator oversees a caseload of 35 patients with high-acuity needs, including serious behavioral health issues and complex socio-economic factors. The primary objectives include enhancing patient access to behavioral health services, primary care, pharmacy assistance, and social support, while minimizing unnecessary emergency room visits and hospital admissions, ultimately improving overall patient health outcomes.
Key Responsibilities
AREAS OF FOCUS
1) Enroll patients in suitable care management programs, utilizing motivational interviewing techniques to conduct assessments and create comprehensive care plans aimed at fostering self-management and harm reduction.
2) Complete specialized patient evaluations and maintain accurate documentation in relevant systems.
3) Engage with the community to link patients to various clinical and support services, including behavioral health, medical care, pharmacy, social services, legal assistance, public aid, transportation, and housing resources.
4) Deliver care management services across hospitals, health centers, and community settings, ensuring a minimum of two core services or three documented attempts monthly, with at least one face-to-face interaction quarterly for each patient. Adhere to established engagement thresholds for specific programs.
5) Organize case conferences at least biannually, ensuring all care team members are informed of patient status and needs, with timely documentation in the electronic medical record.
6) Maintain proficiency in crisis management and de-escalation techniques to support patients in managing stressors and triggers effectively.
7) Monitor critical alerts related to patient transitions of care, ensuring compliance with relevant policies.
8) Utilize a directory of service providers to facilitate patient connections to medical, behavioral health, and social support services, aligning with care plan objectives.
9) Develop and maintain expertise in electronic medical record systems, managing daily schedules to optimize travel and appointment times while ensuring thorough documentation.
10) Exhibit integrity, compassion, accountability, respect, and excellence in all interactions with colleagues, patients, and community partners.
11) Comply with all operational policies and procedures as dictated by applicable regulations.
12) Undertake additional responsibilities as assigned.
Qualifications
CERTIFICATIONS/LICENSES:
Preferred: New York State CASAC (Credentialed Alcoholism & Substance Abuse Counselor), Licensed Clinical Social Worker.
EDUCATIONAL REQUIREMENTS:
1. A Master's degree in Public Health, Public Administration, Business Administration, Social Work, Psychology, or Rehabilitation Counseling; and
2. Two years of full-time experience in a healthcare environment, with at least one year in a supervisory role; or
3. A Bachelor's degree in the aforementioned fields, with three years of relevant experience, including two years in a supervisory capacity; or
4. An equivalent combination of education and experience.
KNOWLEDGE AND EXPERIENCE:
Expertise in mental health, substance use recovery, crisis intervention, and case management.
TECHNICAL SKILLS:
Proficiency in Microsoft Office Suite and electronic medical record systems.
Benefits
NYC Health and Hospitals provides a comprehensive benefits package, including health benefits for eligible employees, retirement plans, loan forgiveness programs, paid holidays, tuition discounts, and various employee discount programs.
