Overview

Community Access provides affordable housing, supportive services, education, training and employment services, integrated rehabilitation and treatment services, and care coordination to individuals with psychiatric disabilities, histories of homelessness, substance use, criminal justice involvement and serious health concerns. The agency’s care management services assist Health Home eligible individuals in various programs to access the services they need to stay healthy and out of emergency rooms and hospitals. Provides direct care coordination services to assigned Health Home program participants; including defining, developing, and implementing person centered care plans to assist participants in their goals in conjunction with relevant providers chosen by the participant. Assistance to program participants uses a person-centered, trauma-informed approach that supports individuals in their recovery and achievement of optimal health outcomes. The Care Coordinator coordinates communication among providers so that information is shared, and the person’s needs are addressed in a comprehensive manner.

Core Principles

The job responsibilities of all staff extend to understanding and incorporating certain principles into their work and into their relationships with program participants. These principles are:

• Program participants’ right to self-determination
• Respectful communication
• Services that support recovery and healing consistent with and nurturing each participant’s cultural background, experience, identity, and values
• Clear professional boundaries to support the limits and possibilities of services

Essential Job Functions:

• Provide care coordination services and outreach, engagement and enrollment to assigned program participants as defined by program and health home requirements.
• Develop and assist in implementing care plans determined by goals and priorities of program participants, including reviewing care plans with program participants, identifying progress, and revising plan as needed.
• Regularly collaborate, coordinate and communicate with care team members including Primary Care Provider (PCP), service providers, family members and collaterals, to support all care plan activities including referrals, transition care planning, integrated care delivery, and follow-up.
• Review new information and complex issues with PCP and multidisciplinary team and incorporate additional recommendations into care plan.
• Administer all standardized and required assessments
• Work with participants to identify barriers to self-care and self-management, and assist in developing skill sets to address those barriers.
• Facilitate follow-up care after hospitalization or emergency room visit.
• Provide participants with necessary health education and materials, including resources on self-management of chronic illnesses.
• Produce and maintain thorough, accurate and timely documentation, including charts and documentation of interactions with participants, services provided, important information and/or events, and contacts with other agencies and service providers, as required by agency policies, Health Home guidelines, and relevant contracts and regulatory agencies.
• Maintain data, statistics and other information and reports for timely and accurate submission.
• Utilize harm reduction strategies when working with individuals experiencing drug, alcohol and related problems, or engaging in other risky and often stigmatized activities.
• Provide crisis intervention, as necessary.
• Attend and participate in supervision, meetings and training sessions, as required.
• Provide holiday, evening and weekend coverage, as necessary.
• Provide coverage for non-assigned program participants, as needed.

This job description reflects management’s assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned.

Job Qualifications

• Minimum of a high school diploma or equivalent (GED) with 4 years of relevant field experience; or
• BA or certificate in related field with 2 years of relevant experience or
• MSW or MA in related field and 1 year of relevant experience.
• Commitment to recovery-oriented practice.
• Be skilled in conflict mediation/negotiation and have an assertive approach to problem solving.
• Experience in collaborative interdisciplinary planning processes.
• Knowledge of Medicaid, Social Security, and other entitlements, preferred.
• Demonstrated competence in written, verbal, and computational skills to present and document records in accordance with program standards.
• Ability to utilize various computer programs, specifically Microsoft Word and Excel.
• Experience working with electronic health records.
• Be creative and flexible.
• Show initiative and be responsible for follow through.
• Willingness to work in the field and travel by public transportation
• Ability to maintain confidential information, as related to position.
• Ability to work independently and as part of a team.
• Bilingual Spanish-speaking, preferred.
• Ability to walk up several flights of stairs.
• Have an understanding, appreciation, and commitment to the philosophy and mission of Community Access.
• Must be fingerprinted and cleared by the New York State Justice Center.

Position Location: 17 BATTERY PL. NY, NY 10004

Position Type: Full Time

Position Salary: $25.34/Hour

Benefits

• Time Off Benefits: 3 weeks of vacation, 5 personal days, 12 sick days, 11 paid holidays, Work Anniversary Day
• Summer Flex Hours
• Comprehensive medical, vision, and dental plans
• Employee Assistance Program (EAP)
• 403(b) Retirement Plan, with Employer Match after 1 year of service
• $500 Annual Employee Wellness Fund for eligible employees
• Pre-tax savings plan (including Flexible Spending Accounts and TransitChek)
• College savings plan
• Paid Family Leave, Short-Term Disability insurance