Evergreen Health

The Float 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) to patients within the Center for Care Coordination. The Float Care Coordinator provides care coordination for patients with a diagnosis of Serious Mental Illness (SPMI), substance use disorder, and other chronic health conditions. The Float Care Coordinator is 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. The Float Care Coordinator may assist the Outreach & Engagement team as needed in times of understaffing. The Float Care Coordinator will maintain a small caseload (up to 20 cases). The Float Care Coordinator will be adaptable to change as required due to the fluidity of the patients served. If educational and necessary work experience qualifications are met, Float Care Coordinators will work with patients enrolled in the Health and Recovery Plans (HARP), including assessing patients using the HCBS Eligibility Assessment, communicating with MCOs regarding Plans of Care, and coordinating referrals to HCBS providers under HARP.

As part of the essential functions of this role, the Float Clinical 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.
• 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. 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.

Qualified Candidate will have a Masters of Social Work, Mental Health Counseling, Psychology, or other related field. Current NYS License (LMSW, LMHC, LCSW) preferred, with one (1) year of qualified experience. OR Bachelor's degree in social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field. Bachelor’s with a CASAC preferred. With two (2) years of qualifying experience. Qualifying experience means post-graduate experience providing direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or linking individuals with Serious Mental Illness, developmental disabilities, or substance use disorders to a broad range of services essential to successful living in a community setting. Must possess a valid NYS Driver’s License and an insured, dependable car to use for client service activities, including transporting clients when necessary. Sensitivity to people living with HIV/AIDS and lifestyle issues is essential.

Job Type: Full-time

Required education: Master’s (plus 1 year experience) (LMSW, LMHC, LCSW preferred); OR Bachelor’s (plus 2 years experience) (CASAC preferred) Or Associates degree ( plus 2 years of experience ).

Required experience: Working directly with people living with Severe Mental Illness (SMI) and Substance Use Disorder (SUD)

Additional requirements: Valid NYS driver’s license and insured, dependable car