Health Home/HH Plus Care Coordinator

Job Scope

As a member of the Care Coordination team and under the supervision of the Program Supervisor/Team Leader, the Health Home / Health Home Plus (HH+) Care Coordinator provides comprehensive, person-centered and intensive care management to adults with complex behavioral health, medical, substance use, housing, and social-service needs. The position serves individuals enrolled in Medicaid Health Home, including members who meet HH+ criteria such as high-need Serious Mental Illness (SMI) and Assisted Outpatient Treatment (AOT), and may also serve assigned non-Medicaid care coordination cases. The Care Coordinator maintains a total caseload of up to 20 individuals, adjusted as appropriate for acuity, HH+ requirements, program needs, and applicable regulatory standards.

This is a field-intensive position serving Manhattan, the Bronx, and Brooklyn. The Care Coordinator meets members where they are - including homes, shelters, hospitals, psychiatric inpatient units, detoxification/rehabilitation programs, outpatient clinics, and community agencies - and plays a central role in transitions of care, engagement, service coordination, advocacy, crisis prevention, and continuity of treatment. The goal is to promote stability, wellness self-management, community tenure, and successful connection to medical, behavioral health, housing, benefits, and social supports while reducing avoidable emergency department use and hospitalization.

Essential Functions

• Manage an assigned caseload of up to 20 HH, HH+, and/or non-Medicaid care coordination members, providing services according to member acuity, risk, eligibility, individualized needs, and applicable program requirements.
• Provide required Health Home core services and HH+ enhanced services, including comprehensive care management, care coordination and health promotion, transitional care, member/family support, and referrals to community and social supports. Ensure required service intensity and face-to-face contacts are completed for HH+ and AOT members.
• Conduct frequent field-based visits throughout Manhattan, the Bronx, and Brooklyn, including member homes, shelters, hospitals, inpatient and outpatient treatment settings, and community agencies.
• Complete comprehensive assessments and develop, implement, monitor, and update person-centered Plans of Care addressing behavioral health, medical, substance use, housing, benefits, social, functional, safety, and other identified needs, strengths, preferences, and goals.
• Coordinate care and maintain effective communication with medical, behavioral health, substance use, hospital, housing, managed care, family/support, and community providers, including interdisciplinary case conferences and follow-up on referrals and treatment recommendations.
• Coordinate transitions of care from hospitals, emergency departments, psychiatric inpatient units, detox/rehabilitation programs, and other institutional settings; complete timely post-discharge follow-up to support medication access, appointments, transportation, housing, benefits, and continuity of treatment.
• Provide assertive outreach, engagement, and re-engagement for members who miss appointments, disengage from treatment, cannot be located, or are at risk for loss of continuity of care, including required diligent-search activities.
• Assess and monitor member risk, functioning, and changes in condition; provide crisis intervention, safety planning, advocacy, and timely escalation/coordination with clinical, supervisory, emergency, and community resources as indicated.
• Assist members in accessing and maintaining needed healthcare, behavioral health treatment, housing, benefits/entitlements, transportation, peer supports, rehabilitation, vocational/educational, legal, and other community resources, including scheduling, referrals, follow-up, and accompaniment when appropriate.
• For members subject to AOT, coordinate with assigned AOT/LGU staff; comply with Kendra's Law and the individual's court order; and complete required AOT/CAIRS, status, and significant-event reporting.
• Complete all required assessments, screenings, Plans of Care, progress notes, encounter/billing documentation, transition documentation, reports, and other records accurately and within established regulatory and agency timeframes. Progress notes must be completed within 24 hours of each reportable service activity.
• Complete and submit required End of Day (EOD) reports each workday, accurately reflecting member contacts, outreach attempts, field activities, documentation status, scheduled activities, and other information required by program leadership.
• Maintain accurate, organized, and audit-ready records in the agency EHR and required State/Lead Health Home systems, and ensure documentation supports services provided and applicable billing requirements.
• Participate in supervision, case review, team meetings, utilization/billing review, quality-improvement activities, required training, and on-call/after-hours coverage when assigned.
• Manage approved member-support resources in accordance with agency policies and required approvals and perform other duties consistent with program goals as assigned by authorized program leadership.

Qualifications

Minimum HH+ SMI staff qualifications (one of the following):

• Master's degree in a qualifying field and at least one (1) year of qualifying experience; OR
• Bachelor's degree in a qualifying field and at least two (2) years of qualifying experience; OR
• Credentialed Alcoholism and Substance Abuse Counselor (CASAC) with at least two (2) years of qualifying experience; OR
• Bachelor's degree or higher in any field with at least three (3) years of qualifying experience, or at least two (2) years of experience as a Health Home care manager serving the SMI or SED population.

Qualifying fields include: social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation/recreational therapy, counseling, community mental health, child and family studies, sociology, speech and hearing, or another human services field.

Qualifying experience includes: providing direct services to individuals with Serious Mental Illness, developmental disabilities, substance use disorders/alcoholism, and/or children with SED; or linking such individuals to a broad range of medical, psychiatric, social, educational, legal, housing, financial, and other services essential to successful community living.

Preferred: Experience with Health Home/HH+, AOT, transitions of care, hospital discharge planning, community outreach, supportive housing/homeless services, co-occurring disorders, and NYC behavioral health systems. Master's degree and/or professional licensure is a plus.