The Adult Home Plus Care Coordinator (Care Manager) functions as a member of an interdisciplinary team to provide care coordination to a caseload of severely mentally ill adults with multiple medical comorbidities and/or co occurring substance abuse disorders and/or medically ill individuals. Advocates for and supports the client, engages with community agencies/health care providers and others on his behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations. Provides clinical support to the Team by providing consultation, education, information around psychosocial and/or substance abuse conditions, interventions, resources to maintain focus on outcomes and best practices.
WE DO NOT PROVIDE DIRECT CLINICAL SERVICE HOURS, NOR DO WE SIGN OFF ON IT.
Seeking experienced care managers to serve as care coordinators for individuals with serious mental illness transitioning from adult home settings to supported housing. The position involves the provision of intensive case management throughout the transition process and accountability for coordinating all aspects of care; significant field work involved.
ESSENTIAL TASKS: To perform this job successfully, an individual must be able to perform each essential duty listed satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions unless this causes undue hardship to the agency.
- Conducts initial and ongoing assessments of assigned clients to document strengths, needs, goals and resources.
- Ability to handle a case load of 12 clients and visit each on a weekly basis
- Participates in the development/documentation /review and update of client centered comprehensive ,integrated, interdisciplinary care plan in consultation with other team members to ensure focus on desired outcomes.
- Maintains effective communications with clients, primary care physicians, substance abuse and mental healthcare providers, family, collateral resources and other Agency staff on behalf of clients.
- Maintains documents, records, statistics, and other related reports in an organized, timely and accurate manner as per policy and procedure.
- Coordinates care planning with other providers of services/ resources to ensure goal directed, collaborative care, including care transitions.
- Works as part of a Care Coordination team; attends and participates in team meetings to provide input/feedback around psychosocial and medical conditions conditions/comorbidities to review client status, update plans and goals, review outcomes to further program goals.
- Acts as a resources/consultant to all team members on psychosocial, medical and/or substance abuse issues and resources.
- Provides telephonic as well as face-to-face outreach, engagement and service planning in the field.
- Acts as a linkage to community services including medical, behavioral, residential, entitlement and any other needed services per interdisciplinary care plan.
- -Work with all providers to ensure that all services are delivered without any interruptions. Be an effective advocate for the participant.
Additional Job Duties & Responsibilities:
- Monitors overall service delivery to clients to ensure coordination and continuity; advocates with service providers/resources as needed.
- Provides crisis intervention and follow-up.
- May be assigned other tasks and duties reasonably related to the job responsibilities.
Educational Requirements:
Bachelor's Degree or Master's Degree in one of the following fields preferred: Social Work, Psychology, Education, Rehabilitation, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Hearing, Physical or Recreational therapy. Degrees in other related areas may be considered.
Skills and/or Experience Required:
- For B.A. level candidates, four (4) years of related human services experience required in providing direct services to mentally, developmentally or other disabled clients in order to link them to a broad range of services essential to successfully living in the community.
- For M.A. level candidates, two (2) years of related human services experience required in providing direct services to mentally, developmentally or other disabled clients in order to link them to a broad range of services essential to successfully living in the community.
- Working knowledge of computer software and electronic health record systems.
- Demonstrated competency in written, verbal, and computational skills to present and document records in accordance with program standards.
- Experienced in and demonstrated comprehensive understanding and working knowledge of the interdisciplinary planning process and the developmental treatment model.
- Knowledge of Medicaid, Social Security and other entitlements preferred.
- Excellent interpersonal skills required.
- You must have the 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