Care Specialist - Full-Time; 4405-207-N

For over 125 years, Catholic Charities Brooklyn and Queens has been providing quality social services to the neighborhoods of Brooklyn and Queens, and currently offers 160-plus programs and services for children, youth, adults, seniors, and those struggling with mental illness. Catholic Charities provides individuals with serious mental illness, complex medical needs and substance abuse issues with comprehensive care coordination and case management services.
Our Children’s Care Coordination team works with the New York State Health Homes Program to help children and families meet their goals and live well cared for in the community. The program serves children/youth and their families ages 0-21. By helping them gain access to services tailored to their individual needs, we help children and families get the support they need to address healthcare goals and gain access to timely and efficient services within their community of choice.
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 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
▪ 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.
▪ 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).
▪ Aids the health home members in identifying the primary care physic