The Health Home Plus Care Coordinator conducts outreach, assessment and service planning to coordinate care for participants with severe mental illness (SMI) who may also have substance use disorders and/or chronic medical conditions. Works closely with clients to implement goals identified during the intake, assessment, reassessment, and care plan process. Maintains contact with the client's extended family and support networks for coordination of care. Monitors client's progress in utilizing services to achieve better health care outcomes while containing costs. Field work required to maintain required contacts per month.

Principal Duties & Responsibilities:

Maintain a caseload of regular Health Home clients and/or Health Home Plus clients. Complete the required billable contacts per month for each client. Conduct home visits and community work in the field including visiting hospitals and emergency rooms. Gather information for and/or conduct outreach, intake, assessment, re-assessments and care plans. Provide care management to a caseload through the coordination of medical, mental health and substance use services. Implement activities to facilitate participant engagement. Participate in case conferences with health home team including, Case Managers and treatment providers. Ensure entitlements, insurance, and benefits are in place. Develop service plans and resolve barriers to effective service utilization. Responsible for assisting Health Home team members in implementing individualized care plans. Monitor client's progress in utilizing services (appointments, treatment, medication, etc.) through telephonic and direct contact. Check that clients receive test results and track that clients follow up with medical directions. Transport and escort clients to/from appointments when needed. Collaborate on care issues with internal clinicians and the participant's assigned Health Home medical provider. Document service information in databases and use electronic systems to track participant activities. Assist in crisis intervention and provide or refer to crisis services. Ensure that clients follow up with aftercare discharge (i.e. fill prescriptions, make appointments).

Knowledge, Skills & Abilities Required:

A masters degree in human service field and one year of experience. A bachelors degree in human service field and two years of experience. A Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and two years of experience. A bachelors degree or higher in ANY field with either three years of experience, or two years of experience as a Health Home care manager serving the Severe Mental Illness (SMI) or serious emotional disturbance (SED) population. Experience must consist of providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse, and/or children with SED; OR 2. Linking individuals with Serious Mental Illness, children with SED, developmental disabilities, and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting Knowledge of health care environments, clinical terminology and health information systems strongly preferred. Must have valid NYS (New York State) Drivers License and be willing to transport clients to appointments using own vehicle. Must provide proof of valid NYS car insurance and Defensive Driving Certificate within 30 days of hire. Valid registration, inspection and Automobile Insurance Liability of a recommended minimum of 100,000/300,000 will also be evaluated upon hire. Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills required. Must be proficient in computer applications or other automated systems such as spreadsheets, Microsoft Office applications, calendar, email and/or database software necessary to perform work assignments.