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Interdisciplinary Care Specialist
2 months ago
JOB SUMMARY:
The Care Coordinator plays a vital role within an interdisciplinary team, delivering essential care coordination services to a designated group of adults facing severe mental health challenges, along with various medical complexities and/or concurrent substance use disorders. This position advocates for clients, collaborating with community organizations and healthcare providers to facilitate access to necessary services aimed at enhancing wellness, promoting self-management, and minimizing emergency interventions and hospital admissions. The Care Coordinator also provides clinical support to the team by offering consultation, education, and information regarding psychosocial and/or substance use conditions, while focusing on outcomes and best practices.
ESSENTIAL JOB FUNCTIONS:
- Conduct comprehensive initial and ongoing evaluations of assigned clients to identify strengths, needs, goals, and available resources.
- Engage in the formulation, documentation, and periodic review of client-centered, integrated care plans in collaboration with team members to ensure alignment with desired outcomes.
- Facilitate effective communication with clients, primary care providers, mental health professionals, family members, and other relevant stakeholders on behalf of clients.
- Maintain organized and timely documentation, records, statistics, and reports in accordance with established policies and procedures.
- Coordinate care planning with service providers to ensure goal-oriented, collaborative care, including transitions of care.
- Participate actively in team meetings, contributing insights regarding psychosocial and medical conditions to assess client progress, update plans, and review outcomes to advance program objectives.
- Serve as a resource and consultant to team members on psychosocial, medical, and substance use issues.
- Provide outreach and engagement services through both telephonic and in-person interactions in the community.
- Act as a liaison to community resources, including medical, behavioral, residential, and entitlement services, as outlined in the interdisciplinary care plan.
- Oversee the delivery of services to clients, ensuring continuity and coordination; advocate with service providers as necessary.
- Deliver crisis intervention and follow-up support.
- May undertake additional tasks and responsibilities as assigned.
- Proficient in computer software and electronic health record systems.
- Strong written, verbal, and computational skills to document and present records in compliance with program standards.
- Comprehensive understanding of the interdisciplinary planning process and developmental treatment models.
- Familiarity with Medicaid, Social Security, and other entitlement programs is preferred.
- Exceptional interpersonal skills are required.
- Willingness and ability to travel regularly, including transporting clients in agency vehicles, using various reliable transportation methods.
- Training specific to designated assessment tools, available services and supports, and client-centered service planning, along with ongoing knowledge of best practices to enhance health and quality of life.
- Mandatory training on the New York State Community Mental Health Assessment instrument and other required training.
- A bachelor's degree in a relevant field; or
- A NYS teacher's certificate requiring a bachelor's degree; or
- NYS licensure and registration as a Registered Nurse along with a bachelor's degree; or
- A bachelor's degree or higher in any field with five years of direct experience working with individuals with behavioral health diagnoses; or
- A Credentialed Alcoholism and Substance Abuse Counselor (CASAC).
- Providing direct services to individuals with Serious Mental Illness, developmental disabilities, or substance use disorders; or
- Connecting individuals with Serious Mental Illness, developmental disabilities, or substance use disorders to a wide range of essential community services (e.g., medical, psychiatric, social, educational, legal, housing, and financial services).
