Complex Care Coordination Manager

1 week ago

New York, New York, United States NYC Health + Hospitals Full time

About NYC Health + Hospitals

NYC Health + Hospitals/At Home extends healthcare services beyond traditional hospital settings, delivering care directly to patients in their communities. With a dedicated workforce of over 600 professionals, Community Care specializes in home care, community care coordination, and management for individuals facing chronic health challenges in various boroughs.

Our mission at NYC Health + Hospitals is to provide exceptional healthcare services to all individuals, without exception. Every team member embodies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence), fostering empathetic communication and collaboration among all stakeholders.

Position Overview

OBJECTIVE OF THE ROLE

Under the guidance of the Care Management Supervisor, the Complex Care Coordinator oversees a caseload of 35 high-need patients with serious behavioral health issues (including mental health disorders, substance use disorders, and HIV) and complex socio-economic challenges. The primary objectives include enhancing patient access to behavioral health services, primary care, pharmacy support, and social services; minimizing unnecessary emergency room visits and hospital admissions; and promoting overall patient wellness and health outcomes.

Key Responsibilities

AREAS OF FOCUS

1) Enroll patients in suitable care management programs (e.g., Health Home, Non-Medicaid) utilizing motivational interviewing techniques to conduct intake assessments and create comprehensive care plans that prioritize self-management and harm reduction.

2) Conduct all necessary patient evaluations (e.g., Health and Recovery Plan) and maintain accurate documentation in designated systems (e.g., CARES, UAS-NY).

3) Engage with the community to link patients to a broad spectrum of clinical and support services, including but not limited to 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 various community settings, ensuring a minimum of two core services (or three documented attempts) per month, including at least one face-to-face interaction quarterly for each patient. Comply with specific service engagement thresholds set for each sub-program.

5) Organize case conferences at least biannually, ensuring that each patient's care team is informed about the patient's status and needs. Respond promptly to inquiries from care team members and document all discussions in the electronic medical record (EMR). Prioritize case conferences for patients showing signs of behavioral health crises or substance use relapse.

6) Maintain proficiency in de-escalation techniques, crisis management, and safety planning to effectively assist patients in managing triggers, coping with stress, and accessing crisis support. Develop and update safety plans for all enrolled patients at least once a year.

7) Monitor and react to critical alerts (e.g., hospital admissions/discharges, arrests) in accordance with policies governing transitions of care.

8) Utilize a directory of service providers to facilitate patient connections to medical, behavioral health, social support, wellness, and family services, in alignment with care plan objectives.

9) Develop and maintain expertise in the EMR system. Effectively manage daily schedules to optimize travel time, appointment lengths, and ensure comprehensive documentation of daily activities.

10) Exhibit integrity, compassion, accountability, respect, and excellence in all interactions with leaders, colleagues, patients, and community partners.

11) Adhere to all operational policies, procedures, and regulations as defined by applicable federal, state, local, and corporate guidelines.

12) Perform additional duties as assigned.

Minimum Qualifications

CERTIFICATION(S)/LICENSE(S):

Preferred: New York State CASAC (Credentialed Alcoholism & Substance Abuse Counselor), Licensed Clinical Social Worker

Qualification Requirements:

1. A Master's degree from an accredited institution in Public Health, Public Administration, Business Administration, Social Work, Psychology, or Rehabilitation Counseling; and

2. Two (2) years of full-time experience in a medically-oriented healthcare environment, with at least one (1) year in an administrative or supervisory role in relevant fields; or

3. A Bachelor's degree from an accredited institution in the aforementioned disciplines; and

4. Three (3) years of full-time experience as described above, including two (2) years in a supervisory or administrative capacity; or

5. A satisfactory equivalent combination of education, training, and/or experience.

KNOWLEDGEABLE IN:

Mental health, substance use recovery, crisis intervention, case management, de-escalation techniques, motivational interviewing, cognitive behavioral therapy.

YEARS OF EXPERIENCE:

A minimum of 2 years' experience supporting populations with chronic illnesses and significant behavioral health and psychosocial needs.

Additional Qualifications

EQUIPMENT/MACHINES OPERATED:

Printer, Scanner, Copier, Fax machine, Laptop, Tablet.

COMPUTER PROGRAMS/SOFTWARE OPERATED:

Proficiency in:

• Microsoft Office Suite (Outlook, Word, Excel)
• Epic Electronic Medical Record (EMR) System
• Various online data portals/systems, e.g., PSYCKES.

How To Apply

If you wish to apply for this position, please apply online by clicking the "Apply Now" button or forward your resume noting the above Job ID.

NYC Health and Hospitals offers a competitive benefits package that includes:

  • Comprehensive Health Benefits for employees hired to work 20+ hours per week.
  • Retirement Savings and Pension Plans.
  • Loan Forgiveness Programs for eligible employees.
  • Paid Holidays and Vacation in accordance with employees' collectively bargained contracts.
  • College tuition discounts and professional development opportunities.
  • Multiple employee discount programs.

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