Evergreen Health At Evergreen Health and our affiliates, we value collaborative, down-to-earth individuals and encourage self-expression. We recognize that our diverse workforce allows us to provide culturally competent care to everyone in our community. The HARP Care Coordinator applies 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 & Family Support and Referral to Community & Social/Support Services) to patients within the Center for Care Coordination. The HARP Care Coordinator provides care coordination for patients with a diagnosis of Serious Mental Illness (SMI), substance use disorder, and other chronic health conditions. The HARP Care Coordinator is responsible for the following outcomes: Reduce utilization associated with avoidable and preventable inpatient stays; reduce utilization associated with avoidable emergency room visits; improve outcomes for persons with mental health illness and/or substance use disorders; and improve disease-related care for chronic conditions. HARP Care Coordinators will work with patients enrolled in the Health and Recovery Plans (HARP), including assessing patients using the HCBS Eligibility Assessment, communicating with MCOs regarding Plans of Care, and coordinating referrals to HCBS providers under HARP. HARP Care Coordinators will also assist HARP enrolled patients with linkage to CORE services, including informing them of the services that are available, referring patients to CORE, and assisting with obtaining NYS LPHA Recommendation Form. As part of the essential functions of this role, the Clinical Care Coordinator: + Delivers core services in accordance with Health Home standards to patients on assigned caseload. Achieves monthly and quarterly productivity expectations. + Completes a comprehensive assessment within 60 days of patient’s enrollment and an annual reassessment inclusive of medical, behavioral, social, and rehabilitative needs. + Completes individualized patient-centered care plan with the patient within 60 days of enrollment and updates monthly to identify patient’s needs and goals, and includes family members and other social supports as appropriate. The Care Plan is also amended annually. + Completes and amends patient crisis plan. Coordinates with service providers and health plans as appropriate to secure necessary care during a crisis, share crisis intervention and emergency information. + Coordinates with multidisciplinary team on patient’s care plan, including but not limited to the primary care physician and/or any specialists involved in the treatment plan. + Links and refers patients to needed services to support care plan including medical and behavioral health care, patient education, entitlement programs, self-help groups, and recovery and self-management. Attends appointments with patient as necessary. Assists patient with transportation needs when necessary to include transportation of the patient when no other means are available. + Conducts diligent search activities to ensure patient engagement and to assess on-going emerging needs in order to promote continuity of care and improve health outcomes. + Conducts annual case review with interdisciplinary team to monitor and evaluate patient status. + Follows up with patient upon notification of ER or inpatient admission and/or discharge and facilities transitions of care within 24-48 hours. + Advocates for interpretation services and utilizes translation line as needed + Maintains complete, current, and accurate patient charts that comply with the Health Home Standards. + If applicable, completes the Eligibility Assessment with patients enrolled in Health and Recovery Plans (HARP). + If applicable, enters data collected from the Eligibility Assessment into the NYS Health Commerce System. Submits the results of the Eligibility Assessment to MCOs for approval and service determination. + If applicable, completes the HARP Health Plan Summary with HARP enrolled patients, communicates with MCOs and Home and Community Based Services (HCBS) providers to ensure referral and linkage to services outlined in the Health Plan Summary. + If applicable, inform HARP enrolled patients of Community Oriented Recovery and Empowerment (CORE) Services, make the referral to CORE, and assist with obtaining the completed LPHA Recommendation Form. Qualified Candidate will have a Masters of Social Work, Mental Health Counseling, Psychology, or other related field. Current NYS License (LMSW, LMHC, LCSW) preferred, with one (1) year of qualified experience. OR Bachelor's degree in social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field. Bachelor’s with a CASAC preferred. With two (2) years of qualifying experience. Qualifying experience means post-graduate experience providing direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or linking individuals with Serious Mental Illness, developmental disabilities, or substance use disorders to a broad range of services essential to successful living in a community setting. Must possess a valid NYS Driver’s License and an insured, dependable car to use for client service activities, including transporting clients when necessary. Sensitivity to people living with HIV/AIDS and lifestyle issues is essential. Job Type: Full-time Required education: Master’s (plus 1 year experience) (LMSW, LMHC, LCSW preferred); OR Bachelor’s (plus 2 years experience) (CASAC preferred) Required experience: Working directly with people living with Severe Mental Illness (SMI) and Substance Use Disorder (SUD) Additional requirements: Valid NYS driver’s license and insured, dependable car What Evergreen Health Offers You: + Remote Hybrid schedules may be available for this position + Opportunities for overtime hours may be available for this position + Multiple comprehensive medical health insurance plans for you to choose from + Dental and Vision coverage at no cost to you + Paid Time Off package that equals 4 weeks of time in your first year + 403b with a generous company match + Paid parking or monthly metro pass + Professional development opportunities + Paid lunch breaks