Outreach Care Specialist- ECM

Amity Foundation, an internationally acclaimed Teaching, and Therapeutic Community is seeking compassionate and enthusiastic individuals with a desire to teach, learn and join our community as a ECM Outreach Care Specialist. This groundbreaking opportunity will allow you to work with our prison and re-entry programs helping the community and will also enhance your training and experience in the field. About Amity:Amity Foundation is a safe place where people can change in an environment that fosters trust; where new values can be formed; responsibility developed, and lasting relationships built. Amity is dedicated to the inclusion and habilitation of people marginalized by addiction, homelessness, trauma, criminality, incarceration, poverty, racism, sexism, and violence. Amity is committed to research, development implementation, and dissemination of information regarding community building. Remembrance, Resolution, Reconciliation, Restoration, Renewal About the Position:The Enhanced Care Management (ECM) Outreach Care Specialist is responsible for the outreach and coordination, improving health outcomes, enhancing satisfaction, and reducing unnecessary healthcare utilization. ECM is a comprehensive, patient-centered approach to healthcare that aims to improve outcomes for high-need populations.  This involves the coordination of medical, behavioral, and social services to address the full range of patient needs, focusing on those with complex and chronic conditions.  ECM programs are designed to optimize care delivery, reduce unnecessary hospitalizations, and improve the overall quality of life for . The intention of our services is to help people who have not been able to get the needed help in terms of Housing, Mental Health, Substance Abuse treatment, and linkages to community resources to help minimize recidivism. The role of the ECM Outreach Care Specialist is to help create a supportive network of services and resources for the client to prevent reincarceration and support long term permanent housing goals.

What you will do:

• Conduct outreach to identify and engage eligible in ECM services, using multiple strategies and modalities for engagement.
• Triage and outreach community members that are referred by MCP/Member Information File and all other computing pathway referrals.
• Interview and conduct assessments of students’ needs, including medical, behavioral, and social factors.
• Develop, implement, and monitor personalized care plans in collaboration with students, their families, healthcare providers, and community resources.
• Monitor and evaluate the effectiveness of care plans and making adjustments as needed to student goals.
• Serve as the primary point of contact for the student, relevant family members, and other supports.
• Operate as part of the student’s multi-disciplinary care team.
• Coordinate care across multiple providers and services, ensuring seamless integration of medical and social care.
• Act as a student advocate, ensuring the student’s needs and preferences are central to care decisions.
• Facilitate regular team meetings to review patient cases, address challenges, and share successes.
• Travel locally to deliver services to students in the community where they live, work, or frequent.
• Document services in the agency’s Electronic Health Record within 72 hours of each service and in compliance with agency policy, as well as contractual, state, and federal regulations.
• Coordinate and link the client to needed mental health, substance abuse, and housing resources.
• Maintained concise and comprehensive case records on all participants seeking services.
• Conduct Outreach and community engagement to educate and engage members of community on ECM Services
• Provide accurate daily and monthly documentation and case notes as per funding source guidelines.
• Attend workshops, meetings, and trainings as requested by supervisor.    
• Performs other related duties as assigned.

What You Will Bring:

• Excellent interpersonal and communications skills and the ability to work effectively with a wide range of constituencies in the community and within the organization.
• Knowledge of contract parameters, objectives, milestones, and other deliverables.
• Knowledge of contracting process and associated local, state, federal and other regulations.
• Ability to integrate budgetary and service utilization data, forecast expenditures, and respond to ensure both effective provider utilization and budget compliance.
• Ability to multi-task, identify problems, provide recommendations to management teams, and implement any applicable systems.
• Ability to work constructively with diverse people and with parties that may have divergent perspectives and interests.
• Abili