Health Home Plus Care Coordinator

At Essen Health Care, we care for that! 

As the largest privately held multispecialty medical group in the Bronx, we provide high-quality, compassionate, and accessible medical care to some of the most vulnerable and under-served residents of New York State. Guided by a Population Health model of care, Essen has five integrated clinical divisions offering urgent care, primary care, and specialty services, as well as nursing home staffing and care management. Founded in 1999, our over 20-year commitment has fueled an unwavering dedication toward innovating a better healthcare delivery system. Essen has expanded from a single primary care office to an umbrella organization offering specialties from women’s health to endocrinology, from psychiatry to a vast array of other specialties. All clinical services are offered via telehealth or in-person at over 35 medical offices and at home through the Essen House Calls program. 

Essen Health Care is the place Where Care Comes Together! We are looking for the most talented and effective individuals to join our rapidly growing company. With over 1,100 employees and 400+ Practitioners, we care for over 250,000 patients annually in New York City and beyond. From medical providers to administration & operational staff, there is a career here for you. Join our team today!

The Health Home Plus Care Coordinator is responsible for Health Home Plus qualified individuals in the following categories: Serious Mental Illness (SMI), HIV/AIDS, Homelessness, and High inpatients ED utilization. The Care Coordinator will also responsible for case retention activities and maintain a caseload at 20 HH+ members or as determined by DOH. Adjustments to case load will be made according to DOH recommendations. Provide follow-up services according to the standards or care and tracking for their caseload.

  Maintain full responsibility for caseload including Assessments, Care Plans, HML’s, timely documentation; Conduct home visits and fieldwork on an ongoing basis      and in accordance with the DOH guidance on minimum standards for Health Home Plus; Conduct case conference to review POC with members, HCBS providers      and supporting team. Obtain necessary records from all primary agencies that are involved with the clients.

· Ensure follow-up by monitoring the quality of services, verifying and ensuring client participation; Provide education and supportive counseling to ensure that          clients understand and follow up with services to which they are referred.

· Ensure that ALL required services are delivered for each member monthly. Services should be prioritized and specific to members’ needs and not prescriptive.

· Ensure that documentation is completed in a timely manner including progress notes written and document the billable and non-billable services within 24 hours.    Be specific and include comprehensive notes for every service provided.

· Participate in the agency quality improvement and professional development programs, attending internal and external training courses and committees.

· Attend weekly care management meetings facilitated by the Care Coordinator supervisor. Work with your supervisor to ensure that your caseload is covered       when you are out of the office.

· Available for evening and weekend telephone crisis intervention and coverage for other staff as needed.

· If bilingual, translate for non-English speaking clients. Additional duties as assigned.

  Master’s Degree in health or human services related field and 1 year of experience in behavioral health setting OR

· Bachelor’s Degree in health or human services related field and 2 years of experience in behavioral health setting; Or a wavier provided through DOH.

· Experience working with HIV/AIDS; mental illness; or those returning to independent living from institutional care; Interest in chronic illnesses, substance abuse    and homelessness.

· Awareness of and sensitivity to cultural and socioeconomic characteristics of populations served.

· Ability to work collaboratively with other professionals.

· Excellent writing and oral communication skills. Good management and organizational skills. · Basic computer skills required.

· Able to work onsite, Monday through Friday during normal business hours, or as needed to carry out the job responsibilities.

$25.00-$27.00 an hour

Essen Health care is proud to be an equal opportunity employer, and we seek candidates who desire to work in and serve an ethnically diverse population.