Agency Profile: Spectrum Health & Human Services respectfully partners with adults, children and families as they recover from behavioral, emotional, mental health and/or substance related disorders by offering individualized and meaningful opportunities of hope, empowerment and support to achieve self-defined improvements in their quality of life. Full-time: 1298 Main Street, Buffalo, NY SUMMARY OF POSITION FUNCTION: The Care Coordinator will apply the essential activities of case management which include assessment, planning, coordination, monitoring and evaluation with the core components (Comprehensive Case Management, Care Coordination & Health Promotion, Comprehensive Transitional Care, Patient and Family Support and Referral to Community & Social/Support Services). The Care Coordinator will be responsible for the following outcomes: to reduce utilization associated with avoidable and preventable inpatient stays, to reduce utilization associated with avoidable emergency room visits, to improve outcomes for person with mental health illness and/or substance use disorders and to improve disease-related care for chronic conditions. MAJOR DUTIES AND RESPONSIBILITIES: + Complete a comprehensive health assessment/reassessment inclusive of medical/behavioral/rehabilitative and long term care and social service needs. + Complete/revise an individualized patient centered plan or care with the patient to identify patient’s needs/goals, and include family members and other social supports as appropriate. + Consult with multidisciplinary team on client’s care plan/needs/goals. + Conduct outreach and engagement activities to assess on-going emerging needs and to promote continuity of care and improved health outcomes. + Consult with primary care physician and/or any specialists involved in the treatment plan. + Prepare client crisis intervention plan. + Coordinate with service providers and health plans as appropriate to secure necessary care, share crisis intervention and emergency information. + Link/refer client to needed services to support care plan/treatment goals, including medical/behavioral health care; patient education, and self help/recovery, and self management. + Conduct case conferences with an interdisciplinary team to monitor and evaluate client status. + Advocate for services and assist with scheduling of needed services. + Coordinate with treating clinicians to assure that services are provided and to assure changes in treatment or medical conditions are addressed. + Monitor/support/accompany the client to scheduled medical appointments. + Follow up with hospitals/ER upon notification of a client’s admission and/or discharge to/from an ER, hospital/residential/rehabilitative setting. + Facilitate discharge planning from an ER, hospital/residential/rehabilitative setting to ensure a safe transition/discharge that care needs are in place. + Notify/consult with treating clinicians, schedule follow up appointments, and assist with medication reconciliation. + Link client with community supports to ensure that needed services are provided. + Follow-up post discharge with client/family to ensure client care plan needs/goals are met. + Develop/review/revise the individual’s plan of care with the client/family + Consult with client/family/caretaker on advanced directives and educate on client rights and health issues, as needed + Meet with client and family, inviting any other providers to facilitate needed interpretation services. + Refer client/family to peer supports, support groups, social services, entitlement programs as needed. + Identify resources and link client with community supports as needed + Collaborate/coordinate with community base providers to support effective utilization of services based on client/family need. + Maintains complete, current and accurate member files which comply with The Health Home Standards. Documents all member related activity in a progress note by the conclusion of the next business day. + Frequent or occasional driving of personal vehicle for purpose of transporting clients in the community and/or site visits (client or work related) + Other duties as requested. SKILLS/COMPETENCIES: + Effective verbal and communication skills + Ability to teach and influence others + Demonstrated ability to work effectively in a team environment. + Demonstrated effective interpersonal relationship and customer services skills + Good organizational and time management skills + Ability to work effectively with people from diverse cultures and socioeconomic conditions. + Actively listens to others to understand their perspective and ensure understanding regardless of barriers. + Homelessness or chemical dependence. Experience with families preferred. + Critical thinking ability + Ability to handle protected health information (PHI) in a manner consistent with The Health Insurance Portability and Accountability Act of 1996. + Knowledge of computerized systems. + Knowledge of local and surrounding area resources EDUCATION REQUIREMENTS: + High School diploma plus 2 years qualifying experience* OR –preferred- Associate’s degree in health, human or education services with 1 year of qualifying experience* OR LPN with experience. + Certified Peer or a peer that has the potential to receive certification. EXPERIENCE: + * “Qualifying Experience” means verifiable full or part-time experience in care coordination with the following populations: person with a chronic illness, and/or persons with a history of mental illness + Must possess a valid Driver’s License with a satisfactory driving record, and possess a personal vehicle for job requirement COMPENSATION: $17.46/hr - $22.26/hr