Health Navigator/Care Coordinator, Care Management Services (CMS)

Position: Health Navigator/Care Coordinator, Care Management Services (CMS)

Function: Responsible for the assessment and engagement of clients around health and wellness and the development of a comprehensive care plan.

Reports to : Director, Care Management Services

Location: Manhattan office with travel throughout Manhattan & the Bronx

Schedule: Mondays-Fridays (9:00am-5:00pm)

Tasks:

• Develops rapport with clients in order to engage them in improving their health and wellness.
• Administers standardized health and psychosocial risk screenings according to Health Home protocols and timeframes.
• Utilizes health screenings to identify interventions and develop a comprehensive care plan
• Collaborates with members of the care team to identify needs and develop a plan to help client achieve optimal health outcomes.
• Implements tasks outlined on the care plan and ensures follow up and continuity of care between client interactions.
• Regularly reviews and updates the care plan to correspond with services being provided.
• Documents all interventions and attempted contacts in the EHR in accordance with program standards.
• Works in collaboration with care providers to address Gaps in Care
• Assesses domiciled client’s living conditions by conducting home visits
• Works with family members and other collaterals of the client’s choice to facilitate planning and delivery of care
• Provides comprehensive transitional care following hospitalization events in accordance with ACMH Critical Time Intervention (CTI) Protocols.
• Reviews new information and complex cases with PCP and multidisciplinary team and incorporates recommendations into the care plan.
• Facilitates care delivery by scheduling appointments, obtaining necessary information, and arranging transportation.
• Utilizes evidenced based practices, such as motivational interviewing, to empower clients to grow and attain goals.
• Embraces the team model by collaborating with members of the team and providing support as needed
• Identifies community resources and makes referrals as needed.
• Supports client goals and serves as an advocate on client’s behalf
• Administers CSD funds (Client Service Dollars) and submits required documentation
• Regularly participates in team meetings and weekly clinical conference
• Attends in-service training as requested
• Duties as assigned by supervisor