Health Home Plus (HH+) Care Coordinator Nassau/Suffolk

The HH+ Care Coordinator functions as a member of an interdisciplinary team to provide care coordination to a caseload of severely mentally ill adults with multiple medical co morbidities and/or co-occurring substance abuse disorders.  HH+ Care Coordinators advocate for and support the client, engage with community agencies/health care providers and others on his/her behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations.        

• Conduct appropriate screening and either performing or arranging for more detailed assessments when needed (e.g., high-risk substance use or mental health related indicators, harm to self/others, abuse/neglect and domestic violence).
• Navigating the mental health service system-including ability to make referrals to mental health housing services, crisis intervention/ diversion, peer support services
• Collaborates with inpatient staff and MCO (as applicable) to affect successful transitions out of inpatient or institutional settings
• Conduct hospital visits for clients admitted for inpatient psychiatric treatment 
• Share and collaborate discharge summaries with outpatient care teams
• Addressing the quality, adequacy and continuity of services to ensure appropriate support for individuals' mental health and psychosocial needs.
• Maintain engagement with individuals who are often disengaged from care, have difficulty adhering to treatment recommendations, or have a history of homelessness 
• Develop service plans and resolve barriers to effective service utilization.
• Accompany clients to/from any appointments when needed.
• Document service information in databases and use electronic systems to track participant activities.
• Assist in crisis intervention and provide or refer to crisis services.
• Extensive field work required, including home visits and community work such as visiting hospitals and emergency rooms when determined necessary.
• Assist with applications for entitlements such as (but not limited to): SNAP, SSI/SSD, HEAP
• Ensure that clients follow-up with aftercare discharge (i.e. fill prescriptions, make appointments).

Skills and/or Experience Required:

• For B.A. level candidates, two (2) years OR for M.A. level candidates, one (1) year of related experience working with individuals with severe mental illness.
• Ability and willingness to regularly travel, in some instances with clients in Agency vehicles to many locations using various modes of reliable and safe transportation
• You must have excellent interpersonal and time management skills.
• Proficiency in email and documentation on electronic platforms.
• Comfortable with fieldwork and navigating social services systems.

Preferred:

• Knowledge of Medicaid, Social Security and other entitlements
• Bilingual /Spanish a plus
• Bilingual /Creole a plus

Benefits 

• Competitive Salary 
• Medical/Dental 
• 401k (with company match) 
• Profit Sharing 
• Employee Referral Program 
• Supplemental Benefits 
• Paid Time off 
• Holidays