Health Home Plus Care Coordinator

Essen Health Care is the largest privately held, multispecialty medical group in New York, providing high-quality, compassionate care to some of the state’s most vulnerable and underserved residents.

Founded in 1999, we’ve grown from a single primary care office into a network of 50+ locations offering urgent care, primary care and specialty services, from women’s health to endocrinology and psychiatry. We also provide nursing home support, care management, and in-home care through our Essen House Calls program. Guided by a Population Health model, our team of 500+ providers deliver care in-person, at home, or via telehealth, ensuring patients get the support they need when and where they need it.

We’re looking for talented, motivated individuals to join our growing team. Whether you’re a medical provider, administrator, or operations professional, there’s a career here for you. Join us in making a real difference in the health of our community.

The Health Home Plus Care Coordinator (Hybrid) 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.