AOT Care Coordinator

Essen Health Care is a growing community healthcare network that provides 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 services in primary & specialty offices, urgent care centers, and nursing homes, as well as house calls for home bound patients; all clinical services are also offered via telehealth. Our Care Management division supports patient-centered care through care coordination, complex care management and helping address health-related social needs. 

Founded in 1999, Essen provides care in all five boroughs of New York City, with a primary focus in the Bronx. Staffed by over 300 primary and specialty care physicians and advanced clinicians, Essen Health Care is one of the largest, most comprehensive private medical groups in New York City. Essen maintains a Clinical Information Services team that maintains our enterprise-wide electronic medical record system, data repository, clinical analytics and population health capabilities. Our Community Services teams create and sustain relationships with community organizations and agencies and health plans. 

Essen health is committed to delivering quality care coordination for all patients. Through that end, Essen Health, recently received designation as ‘Level 3 Patient Centered Medical Home’ by the National Committee for Quality Assurance. Furthermore, Essen has won several awards for its patient care innovations and recently launched Intention Health Ventures to develop and commercialize its technology innovations. 

Reports to:  Care Coordinator Supervisor for HH+ AOT

The AOT care coordinator liaises between the court system, medical system and the community and is responsible for case retention activities, while maintaining a caseload of 15-20 AOT members. The incumbent partners with the members to become  involved in all aspects of their care. The care coordinator delivers quality services to ensure compliance and adherence. The care coordinator meets with the members on a weekly basis at their residence, medical appointments and or in the community to address specific   care plan goals, which include but not limited to addressing medical and psychiatric , behavioral health needs associated to the designatedcourt ordered treatment plan.

In partnership with care team and staff from the Office of Assisted Outpatient Treatment, the AOT Care Coordinator:

• Maintains a caseload of 15-20 AOT members and performs weekly in-person visits with assigned members. As mandates, in-person visits must be performed at the members’ residences or in the community at a convenient location.

• Performs essential transitional care coordination services, including pre-release contacts, day-of-release warm handoffs, assessments and service planning, and assists with entitlements, housing, vocational rehabilitation, life skills, and reintegration services.  
• Connects members to community support services and outpatient health services, including mental health, substance use, behavioral health, harm reduction and medical services.  
• Leads and advocates for the member during crisis response, case conference and IDT meetings, when applicable.
• Documents all encounters and interventions timely and completes initial assessments, reassessments, service care plans, progress notes (using DAP format), and discharge plans.
• Completes all mandated reports in the Health Home Reporting System (FCM) and the Assisted Outpatient Treatment (AOT) portal.
• Attends compulsory training, related to prison re-entry, harm reduction, overdose prevention and behavioral health/criminal justice.
• Maintains ongoing communication and partnership with DOCCS/Parole, the Department of Homeless Services (DHS), and the Office of Mental Health (OMH).
• Provides care coordination services from strength-based, recovery-oriented, trauma-informed, and culturally appropriate approaches.
• Performs other duties as requested by immediate supervisor.

• Bachelor's degree in social services, Human services and Social Sciences or, master's degree in social work with   license to practice in New York State. At least six years in the provision of community-based social and case management services.
• At least two years of experience in a professional environment providing care coordination or clinically based interventions to individuals involved in the criminal justice systems.
• At least two years in providing direct services to people who are seriously mentally ill, intellectually disabled or chemically dependent.
• Knowledge of community resources for individuals with serious mental illness, developmental disabilities, or alcoholism or substance abuse.
• Professional experience in navigating services for homeless and substance use populations with medically and psychiatrically complex needs.

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.