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Care Coordination Floater

Company: Horizon Health Services
Location: Tonawanda
Posted on: April 8, 2021

Job Description:

If you are a job seeker with a disability and require a reasonable accommodation to apply for one of our jobs, you will find the contact information to request the appropriate accommodation by visiting the following page: Description Are you looking to start or continue your career within the human services field? Do you want to work in a role where you will be able to help our community daily? Apply to be a Care Coordinator today! "The best thing about coming to work at Horizon Health Services is knowing that I am given the opportunity to make a difference within the community, and, knowing that I am supported by my amazing team!" What will my day look like? We know that helping our community is your priority! Horizon wants to make sure that you are can do that with ease by making sure you are supported. From a great onboarding experience to continuous training you will always have the resources you need to be successful! Here is some more information about the job that you should probably know---

  • Coverage of a caseload that is weighted at a total of 100+ for staff that may be on medical leave or for staff vacancies. Members receive a minimum of one or two monthly face to face contacts, depending on their status, as well as one or two monthly provider/HCBS/MCO/family contact. Additional contact may be necessary and is at the discretion of management.
  • Willing to make home visits to members in potentially undesirable locations in various home environments.
  • Successfully complete the HARP Assessment training in the Uniform Assessment System for New York (UAS-NY). Performs HARP assessments/reassessments; maintains an active Health Commerce System (HCS) account.
  • Promote a team approach within the Care Coordination Department.
  • Interviews members to assess member needs, prioritize needs, identify barriers in addressing needs, and strategize to overcome barriers.
  • Assist members in the development of the care plan, self-management goals and strategies; documents them in the Electronic Medical Record (EMR).
  • Assist member with coordination of appointments including, but not limited to, scheduling, rescheduling, providing appointment reminders and arranging transportation.
  • Works closely with the interdisciplinary care team including PCP, psychiatrist, therapist, residential services, substance abuse treatment program, etc.
  • Develops interdisciplinary care plan and other case management tools by participating in meetings; coordinating information and care requirements with other care providers; resolving issues that could affect smooth care progression; encouraging peer support; providing education to others regarding the care management process.
  • Monitors the delivery of HCBS services to ensure members are following through with goals identified in their care plans.
  • Attend clinical meetings to review members' utilization of services.
  • Complete case record reviews.
  • Updates HARP Plan of Care once notice of decisions are received, final approval, every 6 months or if a significant change has taken place.
  • Ensures all documentation of member interaction is completed timely in the EMR
  • Completes other required paper work such as mental health and drug court reports, consents, etc.
  • Respects members by recognizing their rights; maintaining confidentiality.
  • Maintains quality service by establishing and enforcing agency standards.
  • Maintains member care database by entering new information as it becomes available; verifying findings and reports; backing up data.
  • Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; benchmarking state-of-the-art practices; participating in professional societies.
  • Conducts home visits and participates in member appointments and case conferences in the community with other providers.
  • Researches community resources and government benefit programs to determine eligibility criteria, provide appropriate referrals, and perform follow up activities for referrals.
  • Outreaches to members to facilitate keeping scheduled appointments; arranges for metabolic and periodic preventive screening, per evidence based guideline standards and review results with members and their family.
  • Coordinates services between members and extended care team providers to ensure that integrated care plan is fully implemented.
  • Regularly reviews member information from care team to identify members requiring outreach and engagement.
  • Assist members in identifying the necessary skills to promote self-sufficiency, medical adherence, and the ability to access and maintain community resources on their own.
  • Reassess members annually by completing the Health Home Comprehensive Assessment located in our EMR system.
  • Utilize MAPP, HEALTHeLINK, EPACES, GSI, Netsmart, Cerner, or any other identified programs or EMRs to obtain pertinent information for proper coordination of care
  • Other duties, as assigned by supervisor and as program needs change Side Note: You must possess a clean NYS driver's license and have reliable transportation to travel locally on a regular basis. Why do I want to work for Horizon? Besides the fact that we have been named a Best Place to Work for 12 (yes 12!) years in a row? At Horizon you are able to come to work knowing that you are making a difference in someone's life. You will also work around people that want to make a difference just as much as you!
    • Collaboration. Not only will you be able to work with other Care Coordinators, you will also be able to work with counselors on how to best help and support our patients. The more the merrier, right?
    • Various training opportunities. Who doesn't love professional development? Horizon University offers more clinical and nonclinical trainings than we can count. There's always something new to learn here.
    • Seasonal employee outings. This gives you built in time within your week to enjoy some self-care, wellness, and team building!--
    • Summer hours. Every Friday in the summer you will be able to start your weekend at 1pm. Who doesn't want to extend their weekend by a half a day?! What has prepared me for this opportunity?
      • A bachelor's degree in any of the following: child & family studies, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreation therapy, rehabilitation, social work, sociology, or speech and hearing; OR a NYS licensure and current registration as a Registered Nurse and a bachelor's degree; OR a--bachelor's level education or higher in any field with two years of experience working directly with persons with behavioral health diagnoses; OR a credentialed Alcoholism and Substance Abuse Counselor (CASAC) AND--
        • Two years of experience providing direct services to persons diagnosed with mental disabilities, developmental disabilities, alcoholism, or substance abuse OR linking persons who have been diagnosed with mental disabilities, developmental disabilities, alcoholism or substance abuse to abroad range of services essential to successfully living in a community setting. Please note a--Master's degree in a related field may substitute for one year's experience.-- Location Care Coordination has merged Genesee, Niagara and Erie County teams into a new facility located in 1000 Young Street in Tonawanda, NY. Within this area you would specifically be responsible for the (Genesee, Niagara or Erie) county members. Hours Monday through Friday-no weekend hours in this position! This position has a schedule from 8:00 a.m.-5:00 p.m. but we are flexible and want to work with your schedule as well! Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)

Keywords: Horizon Health Services, Tonawanda , Care Coordination Floater, Other , Tonawanda, New York

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