Albany, New York
Whitney M. Young Jr. Health Ctr.
Care Coordination is provided by health educators, social workers, and professionals with related health and human service experience. The Community Prevention and Treatment Services (CPTS) Care Coordinator participates in a multidisciplinary team in partnership with the Clinical staff, Peer Support Counselor, and other appropriate staff. The role of the Care Coordinator is to assess the needs of the patients as well as the needs of the patient’s family and support system; to develop an individualized Service Plan; to arrange, coordinate, monitor, and evaluate service delivery to meet the patient’s self-identified goals and address challenges identified in the assessment and Service Plan. The Care Coordinator will also advocate on behalf of the patient and act as liaison to external organizations providing complementary services.
• Develops comprehensive, individualized Service Plans in collaboration with the Social Worker and Peer and Clinical Team
• Coordinates service delivery and activities required in implementing the Care Plan.
• Conduct face-to-face Intake: Biopsychosocial assessments, and other paperwork as needed, including completion of all required forms (informed consent, confidentiality, grievance, release of information, and rights & responsibilities forms.)
• Demonstrates knowledge of development across the lifespan, cultural and linguistic norms of minority populations and subpopulations, and awareness of socioeconomic health disparities as it pertains to medical and mental health treatment and prognosis.
• Interprets age-specific and cultural responses to treatment to improve health outcomes.
• Provides education, encourages retention in care, adherence to medical treatment, and strategies for promoting chronic disease self-management.
• Identifies the appropriate time for integrating family or the patient’s informal support network to help achieve clinical objectives.
• Manages referrals to appropriate agencies required to assist the client in achieving the goals and objectives identified in the Service Plan.
• Participates in case conferencing with the other members of the CPTS clinical team, as appropriate, and as required by acuity level.
• Participates in weekly HIV/HCV/PrEP Clinical Care Review
• Assist clients to access programs that will help pay for medical care and prescriptions.
• Conducts client-specific advocacy related to supportive services.
• Reviews clients’ utilization of services.
• Participates in outreach and engagement activities.
• Oversees transfer, inactivation, and discharge processes.
• Ensures timely documentation in the electronic health record and in designated State and Federal data management systems.
• Participates in Performance Improvement/Continuous Quality Improvement activities, as assigned.
• Demonstrates excellence in both internal and external customer service.
• Understands and is able to effectively communicate HIPAA compliance, corporate compliance and client confidentiality.
• Ensures and/or remains in compliance with local, state, and federal regulation, i.e. DHHS HRSA and NYSDOH, and all accreditation standards (e.g. Joint Commission and NCQA-PCMH).
• Adheres to the National Patient Safety Goals as defined by the Joint Commission and Whitney M. Young Jr. Health Center.
• Completes other duties as assigned.
Associate’s degree in human service related field in addition to 3 years’ experience in case management with the following populations: persons with HIV/AIDS, mental health, and/or substance use. Strong written and verbal communication skills; Provides excellent customer service and demonstrates a high level of cultural competency. Has the ability to adhere to strict confidentiality guidelines. Have a working knowledge of computers and Microsoft Office program.
Bachelor’s degree in in Psychology, Sociology, Social Work, Nursing or related field with 2 years of work experience in case management with one of the following populations: persons with HIV/AIDs, mental health, and/or substance use. Bilingual (English/Spanish). Experience with New York State Department of Health AIDS Institute Reporting Software
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other legally protected status.