Health Homes Care Coordinator

Perform outreach and enrollment activities to assist consumers in the community understand the benefits of, and enroll in, a Health Home. Coordinate services to decrease high risk medical and/or behavioral health costs for individuals being served in Health Homes.  

Responsibilities

1.     Identify areas within the region where people with high medical risks are encouraged to seek health care, and conduct Western NY Independent Living (WNYIL), Inc. Outreach and Engagement.

2.     Determine Medicaid eligibility through ePaces for all individuals; if Medicaid eligible, collaborate with Medicaid Analytics Performance Portal/Aged Blind and Disabled (MAPP/ABD) and work together to certify/recertify, if individual desires.

3.     Coordinate WNYIL, Inc. staff to meet established benchmarks in required amount of time, set by the Health Homes, for individuals being served.

4.     Ensure WNYIL, Inc. staff follow-through on decreasing or eliminating barriers that individuals may face in keeping appointments through coordination with WNYIL, Inc. direct service staff.

5.     Coordinate WNYIL, Inc. direct service staff to collaborate with the individuals’ community and family supports to meet identified social needs.

6.     Recruit individuals who qualify for Medicaid and have two (2) or more chronic health conditions, serious mental illness, HIV/AIDS or significant risk factors that can be addressed with coordinated care (i.e. Homelessness).

7.     Facilitate and document face-to-face referrals from community providers.

8.     Contact potential Health Homes enrollees via phone, letter and face-to-face contact.

9.     Enter all required data into all required program reporting databases (including but not limited to, Care Plans, referrals and assessments).

10.     Maintain acceptable billing levels per month to achieve salary.

11.     Accurately document consumer services and required paperwork in WNYIL’s Service Performance Record (SPR) database, as well as the Electronic Consumer Record (ECR), within two (2) working days of the date of service.

12.     Participate in maintaining a neat, clean and safe work environment.

13.     Perform other job-related duties as assigned by the supervisor.

Qualifications

·      Must possess a Bachelor’s degree in one of the following areas: Child & Family Studies, Community Mental Health, Counseling, Education, Nursing, Occupational Therapy, Psychology, Recreation, Recreation Therapy, Rehabilitation, Social Work, Sociology or Speech and hearing.

OR

NYS licensure and current registration as a Registered Nurse AND a bachelor’s degree

OR

Bachelor’s level education or higher in any field with five (5) years’ experience working directly with persons with behavioral health diagnosis OR a CASAC.

·   Must have a Master’s degree in one of the fields listed above, with one (1) year experience

OR

Bachelor’s degree identified above with two (2) years’ experience in the following: either 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 a broad range of services essential to successfully living in a community setting.