Clinical Care Coordinator

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The Clinical Care Coordinator provides care coordination for clients with a diagnosis of Severe and Persistent Mental Illness (SPMI) and other chronic conditions and clients enrolled in Health and Recovery Plans (HARP). The Clinical Care Coordinator is also responsible for assessing clients using the HCBS Eligibility Assessment, communicating with MCOs regarding Plans of Care, and coordinating referrals to HCBS providers under HARP. Services include the activities of case management, inclusive of assessment, planning, coordination, monitoring and evaluation with the core components (Comprehensive Case Management, Care Coordination & Health Promotion, Comprehensive Transitional Care, Patient & Family Support and Referral to Community & Social/Support Services). Additional duties may include crisis intervention and lethality assessment.  As part of the Essential Function for this role, the Clinical Care Coordinator:

· Completes the Eligibility Assessment with clients enrolled in Health and Recovery Plans (HARP)

· Enters data collected from the Eligibility Assessment into the NYS Health Commerce System. Submits the results of both Assessments to MCOs for approval and service determination

· Completes the HARP Plan of Care with HARP enrolled clients, communicates with MCOs and Home and Community Based Providers (HCBS) to ensure referral and linkage to services outlined in the Plan of Care

· Complete a comprehensive health assessment/reassessment inclusive of medical/behavioral/rehabilitative and long term care and social service needs

· Complete/revise an individualized patient centered plan or care with the patient to identify patient’s needs/goals, and include family members and other social supports as appropriate

· Consult with multidisciplinary team on client’s care plan/needs/goals

· Conduct outreach and engagement activities to assess on-going emerging needs and to promote continuity of care and improved health outcomes

Qualified Candidate will have a Masters of Social Work, Mental Health Counseling, Psychology, or other related field with one (1) year of qualifying* experience OR Bachelor’s Degree in social work, psychology, or other human services field with two (2) years of qualifying* experience. Qualifying experience means post-graduate experience providing direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or linking individuals with Serious Mental Illness, developmental disabilities, or substance use disorders to a broad range of services essential to successful living in a community setting. Must possess a valid NYS Driver’s License and an insured, dependable car to use for client service activities, including transporting clients when necessary. Sensitivity to HIV/AIDS and lifestyle issues is essential.

Job Type: Full-time

Required education:  Master’s (plus 1 year experience) (LMSW, LMHC, LCSW preferred); OR Bachelor’s  (plus 2 years experience) (CASAC preferred)

Required experience: Working directly with people living with Severe Mental Illness (SMI) and Substance Use Disorder (SUD)

Additional requirements: Valid NYS driver’s license and insured, dependable car

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