STATEMENT OF THE JOB :
Under the direct supervision of the HH Team Supervisor, the Care Specialist has overall day-to-day responsibility and accountability for coordinating all aspects of care for assigned health home serving children members with complex medical and / or psychiatric co-
morbid conditions and for facilitating their access to the full range of medical, behavioral health, substance use, social and psychosocial services in the community, in an efficient and effective manner.
Duties of the Care Specialist focus on integration and coordination of physical health, mental health and social service needs.
The Care Specialist has to become an active participant in all phases of care transition to assure that members receive all required mental and medical follow up care and services, and must also take action around re-
engagement of members who have become lost to care.
The Care Specialist electronically monitors and tracks data regarding health home member and alerts all members of the Care Team when follow-up is required.
DUTIES AND RESPONSIBILITIES : ESSENTIAL FUNCTIONS :
ESSENTIAL FUNCTIONS :
Demonstrates commitment to the vision of Health Home and strategic priorities to ensure their achievement.
Accountable for engaging and retaining Queens health home members in care, coordinating and arranging for the continuous provision of services, supporting adherence to treatment recommendations, monitoring and evaluating their needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care.
In collaboration with the health home members, their family and / or caregivers, and other service providers develops, manages and coordinates a comprehensive individualized person-
centered care plan that coordinates and integrates the continuum of medical, behavioral health services, rehabilitative, long term care and social service needs and clearly identifies the primary care physician / nurse practitioner, specialists, behavioral health care providers, care manager and other providers directly involved in the individual’s care.
Ensures the availability of priority appointments for health home members to care services including physical, psychiatric, and substance abuse within their health home provider network to avoid unnecessary, inappropriate utilization of emergency room and inpatient hospital services.
Promotes evidence based wellness and prevention by linking health home members with resources for smoking cessation, diabetes, asthma, hypertension, self-
help recovery resources, and other medical services based on individual physical needs and preferences.
Tracks and shares health home members’ information and care needs across providers by utilizing electronic databases and monitors outcomes and initiate changes in care, as necessary, to address health home members’ needs.
Reassesses needs for Health Home services and reviews health home members’ historical or targeted clinical measurements (i.
e. number of ER visits and inpatient psychiatric admissions).
Identifies potential barriers to successful care and resolutions to those barriers.
Completes contact notes, incident reports, and other required documentation and maintains accurate recordings in electronic case files in a requested timely fashion.
Completes CANS-NY training and examination to properly assess clients being served.
Checks that health home members receive test results and tracks that patients follow up with medical directions. Prepares and follows-
up on a list of health home members who need preventive or metabolic screening, appointment reminders.
Outreach via phone to health home members between visits (check on self-care, medication fills, treatment plan, schedules visits, tests / follow-
up) Monitors that the health home member completes post-visit follow-up (fill prescriptions, make appointments).
Monthly Face to face visit with client / child as well as monthly follow up (telephonic or face to face) with various providers / collaterals (i.
e. guidance counselors, parents / guardians, therapists, ACS etc.)
Aids the health home members in identifying the primary care physician and multidisciplinary teams of medical, mental health, chemical dependency treatment providers, social workers, nurse’s nutritionists / dieticians, pharmacists, outreach workers including peer specialists and other care providers to assure that enrollees receive needed medical, behavioral, and social services in accordance with a plan of care.
Responsible for maintaining the security of all data files and employ approved methods of data encryption to prevent theft of personally identifiable information.
Refer Queens health home members to peer supports and coordinate peer supports, support groups, and self-care programs to increase client’s and caregivers knowledge about the individual’s diseases, promote the health home members’ engagement and self-
management capabilities, and help the to improve adherence to their prescribed treatment order to allow them to make informed decisions.
Assure timely and comprehensive transitional care from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing or treatment facility) to follow-
up with post discharge interventions in order to prevent health home member’s avoidable readmission after discharge and to ensure proper and timely follow up care.
Develops and maintains health home networks with primary medical and specialty practitioners and mental health providers, substance abuse service providers, community based organizations, managed care plans, emergency rooms, hospitals, and residential / rehabilitation settings, community-
based services to ensure coordinated, and safe transition in care for its patients who require transfer to / from sites of care.
Utilizes regional health information organizations (RHIOs) and other data systems to track and share health home members’ information and care needs across providers, monitor their outcomes, and initiate changes in care as necessary to provide the health home prompt notification of an individual’s admission and / or discharge to / from an emergency room, inpatient, or residential / rehabilitation setting and address immediate needs in order to maximize optimum care and timely treatments, services and referrals.
Utilizes and electronically tracks all specialty medical, behavioral, and support service referrals made for health home members, and ensures that the member follows up and receives all of the care they need.
Tracks and arranges appointments, educate health home members and coordinate all aspects of the member’s health and community services.
Able to utilize technology conferencing tools including audio, video and / or web deployed solutions and accountable for hand-
held devices (I Phone, Blackberry, I Pad, Tablets, Laptops, etc.).
Makes sure that health home members’ entitlements, insurance and benefits are in place. Provides interpreter services as required.
Responsible for direct service provision of services to the consumer based on needs as established and documented in comprehensive assessments and service plans.
This will be re-evaluated and adjusted in the care coordination platform every 6 months or as needed (per goal change or change in life event).
Work schedule includes holiday coverage to accommodate the coverage needs of the program when required. 24 hours / seven days a week availability to provide information and emergency consultation services and provide escorts to health home members from ER, hospital and other settings to alternative level of care.
Reports to Behavioral Health Services Administration and / or Agency Administration issues that may have a negative impact on the reputation of the Agency, client and / or staff welfare or any corporate compliance issue.
Cooperates with any and all investigations conducted by the Agency, funding sources and any other authorized agencies / entities.
NON-ESSENTIAL FUNCTIONS :
Attends required in-service programs and trainings.
Collaborate with program management in the identification of developing marketing strategies.
Request in a timely fashion scheduled vacation and time off request from the Clinical Director to ensure continuous coverage of program’s activities.
Performs other related duties as requested or assigned by agency management.
As this is an evolving program, additional responsibilities may be added and / or revised.
Participates in committees as directed.
SPECIFICATIONS FOR EDUCATION / CERTIFICATIONS / LICENSES :
Bachelor’s degree in social work, psychology or a related health / human services field with two (2) years of direct work with the target population.
OR Degree / certification in Medical and Clinical Assistance or Health professional field.
SPECIFICATIONS FOR EXPERIENCE AND TRAINING :
The position requires a combination of skills in the areas of crisis intervention, time management, psychosocial rehabilitation skills
Position requires CANS-NY certification.
Ability in linking clients to a broad range of services essential to successfully living in a community setting (e.g., medical, psychiatric, social, educational, legal, housing and financial services).
Must have excellent communication skills.
Cross-cultural competency, outreach, interviewing, listening, advocating, linking, negotiating, engagement, monitoring and clinical assessment skills are essential.
Excellent computer skills are necessary.
Knowledge of the community medical resources and their financial requirements.
Good oral and written communication skills.
Fluency in second language preferred.
SPECIFICATIONS FOR PHYSICAL REQUIREMENTS :
Ability to work flexible hours and days including weekends / evenings / holidays according to needs of a 24 / 7 program.
Regularly required to talk, hear, walk, stand & sit.
Able to lift up to 10 pounds.
Able to climb stairs and make home visits.
Able to stretch and bend to retrieve files.
Able to operate a computer keyboard, mouse, & office equipment.
Able to read printed materials and computer screens.
Able to write.
Able to sit and work on the computer for long periods of time.
Able to travel to multiple locations as needed.