Care Coordinator, Mental Health (WFH)

Hours

  • Monday through Friday, hours vary and some weekends/evenings may be required

Position Overview:

If you are a licensed social worker or RN with at least 2 years of experience and are interested in helping to develop a new program dedicated to adult patients whose social and mental health needs are complicating medical care, we would like to talk with you. The ideal candidate will have a demonstrated ability to develop new programming, excellent communication and teaching skills, the interpersonal skill to work collaboratively with diverse clinical teams, and experience in collaborating with community partners in the Central New York area. The successful candidate would join a team of healthcare professionals who are passionate about supporting patients as they learn to navigate the healthcare and community-based resource systems. The Care Coordinator for Population Health, Mental Health will be a key resource for our clinical teams and patients with mental health and socio-economic needs.

Responsibilities:

  • Assess socio-economic needs contributing to health issues, identify appropriate interventions, and develop and implement a patient-centered goal and care plan.
  • Identify mental health needs contributing to health issues, identify appropriate interventions, and develop and implement a patient-centered goal and care plan. Work collaboratively with the population health psychiatrist.
  • Identify appropriate community resource providers to support care plan and facilitate patient connections. Track community-provided interventions and their contribution to the patient centered care plan. Collaborate to implement the patient-centered care plan.
  • Collaborate with the patient’s primary care and mental health providers, and their clinical teams.
  • Analyze family, caregiver and “trusted other” relationships and incorporate into care plan as appropriate.
  • Addresses guardianship, level of care, transfer to assisted living or long-term care, medical decision-making, end of life and complex family issues.
  • Educates patients, families, care givers and “trusted others” to support the patient-centered care plan
  • Determine and manage outcomes, ensure continuity of care through planning, utilization of resources and analysis of variances.
  • Acts as a resource to the population health department to advise staff on local, state and federal programs, or other community resources or regulations related to social issues.
  • Assist in developing and implementing population health initiatives.
  • Determine and manage outcomes, ensure continuity of care through planning, utilization of resources and analysis of variances.
  • Support patient self-management of disease and behavior modification interventions.
  • Function as a contact person for patient, family, health care team members, community resources and employees as necessary.
  • Bill as appropriate for care management services and educate the patient as appropriate.
  • Assist the patient in navigating the health care system and community resources.
  • Promote clear communication among care team and treating clinicians by ensuring awareness regarding patient care plans.
  • Ensure adherence to clinic and departmental policies and procedures. Patient care assignment will include adult and geriatric age groups.
  • Initiate patient and family conferences as needed.

Minimum Education/Certification Licenses:

Required

  • Current New York State social work license, LMSW or LCSW, or
  • Current New York State RN License

Experience (required) 

  • Minimum of 2 years of experience as a licensed social worker or RN with mental health focus.
  • Experience in coordinating care for patients across the care continuum, including homebased, primary and specialty care and long term care.
  • Experience in establishing working relationships with community service partners and medical teams.
  • Experience in program and process assessment, and improvement.
  • Knowledge of provider community and community resources in the Syracuse NY/CNY areas.
  • Comprehensive knowledge of insurance company principles and outpatient delivery systems.
  • Highly organized and well-developed oral and written skills
  • Demonstrates sound judgement, decision making, and problem solving skills
  • Able to maintain confidentiality with all aspects of information in accordance with Practice, State and Federal regulations
  • Confidence to advocate and communicate to other community health care organizations and personnel on behalf of patients.
  • Self-disciplined, energetic, passionate, and innovative.

 Experience (preferred) 

  • Minimum 5 years clinical experience.
  • Experience working in primary and long-term care with adult patients

Crouse Medical Practice, PLLC is an Equal Employment Opportunity Employer-M/F/D/V. To apply, please, complete our Online Application or  email your resume to Human Resources at humanresources@crousemed.com.