Project Coordinator, Health Home Plus

Program Description:

Health Home Plus (HH+) is an intensive Health Home Care Management (HHCM) service established for defined populations with Serious Mental Illness (SMI) who are enrolled in a Health Home (HH) serving adults.

Position Overview:

The person filling this position is responsible for: aiding qualified individuals who require social service assistance. This includes interviewing and evaluating clients, formulating service plans and goals, in order to aid clients in meeting their Mental Health and Medical needs. This should be done through the use of appropriate community resources/referrals. Field work is mandatory, each client must be seen a minimum of 2 times per month or as needed, specific to client need. Project Coordinators are expected to provide intensive case management services to select populations (as defined by the New York State Department of Health) who also have a Serious Mental Illness (SMI) and are enrolled in a Health Home (HH) serving adults. Case Management services are provided for a period of up to 1 year, possibly longer, dependent on client need.

• Carry and maintain a caseload of up to 20 clients, providing assessments, developing care plans, provide service referral/navigation, and crisis intervention, as needed.
• Comply with any and all Federal, State, City and CAMBA security and privacy polices intended to protect the security and privacy of individually identifiable health information.
• Conduct required field work. All clients must be seen, in-person, a minimum of two times per month. Additional visits may be required depending on client need.
• They would also require two additional telephonic calls, for a total of 4 encounters per month.
• Work with clients to break through barriers to client goals and to assist clients in advocating for themselves and in moving toward self-sufficiency.
• Recommend and implement strategies to persuade clients to participate more fully in this process.
• Monitor clients' progress toward their service plans goals via regularly scheduled telephone contact and/or face-to-face home and office visits, and document via service plan outcomes and detailed progress notes (i.e. time of service, type of service, etc.)
• Act as client liaison/client advocate with outside organizations regarding such matters as education, healthcare, housing, legal issues, entitlements, etc.
• Escort clients to appointments (educational, medical, social service, etc.)
• Follow-up with clients for a period of time after successful completion of their primary goals to assure client stability.
• As necessary reach out and market the program to the community in order to recruit clients.
• As needed prescreen clients over the telephone for eligibility and may schedule appointments for possible enrollment.
• Assist clients in completing applications for benefits and entitlements and may process applications on clients' behalf as needed.
• Other duties as assigned.

Education, Licenses and/or Certifications Required:

• A Master’s degree in one of the qualifying fields and one (1) year of Experience; OR
• A Bachelor’s degree in one of the qualifying fields and two (2) years of Experience; OR
• A Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and two (2) years of Experience;
• A Bachelor’s degree or higher in ANY field with either: three (3) years of Experience, or two (2) years of experience as a Health Home care manager serving the SMI or SED population
• Qualifying fields include education degrees featuring a major or concentration 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.

Minimum Experiences and Skills Required:

• Providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse, and/or children with SED; OR
• Linking individuals with Serious Mental Illness, children with SED, developmental disabilities, and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services).
• Strong communication skills are required, as you must be able to effectively communicate with resistant or difficult clients.
• Candidates will also be expected to conduct care conferences with medical providers from different specialties.
• Strong written skills are required.
• Time management is essential, candidates are expected to handle competing priorities in a timely fashion.
• Candidates must have the ability to work with Microsoft Office; Word, Excel etc. and also utilize web-based reporting platforms.

Preferred Qualifications:

• Bi-lingual English and Spanish.