The Care Coordinator will play an integral role in our Patient-Centered Medical Home/Medicaid Health Home and will work closely with the whole care team to ensure quality patient care. This position will be responsible for the overall implementation of Care Coordination activities throughout AMS. Such activities include but are not limited to:

• Integration, facilitation, and coordination of care for at risk patients across the health continuum.

• Developing relationships with local hospital case managers, emergency room staff, and with key members of the entire Health Home Network in order to facilitate the Care Transition Process.

• Ensuring all necessary post discharge needs are met and follow up appointments with PCP are scheduled.

• Focusing on high risk and chronic care management for Medicaid and non-Medicaid patient populations in order to provide Pre-visit Planning, Medication Management, and Self-Care Support.

• Provision of comprehensive care management including ongoing assessment or review of medical and psychosocial needs, education, risk screening/preventative care, service coordination, referral and transition care as needed.

• Tracking performance of clinical outcomes

• Handling other related functions as assigned

The Care Coordinator will be assigned to manage their own patient caseload and may also be required to rotate on-call responsibilities with other Care Coordinators as needed to ensure 24hour/day and 7day/week care for crisis intervention. The Care Coordinator will communicate with providers and care team on an as needed basis to discuss changes in patient condition that may necessitate treatment change and will attend regular case review meetings. The Care Coordinator will work closely with the Interdisciplinary Team to ensure appropriate utilization and provision of resources for patients including referrals to outpatient medical, mental health and substance abuse services. In addition to creating/altering the care plan, the Care Coordinator will ensure that a participant/family values assessment is completed.

Caseload will be determined by the level and intensity of care management to be provided.

Education/Experience:

Baccalaureate prepared RN or Social Worker or CCM or eligible to sit for CCM or two years acute care/home

care and/or case management experience preferred. Master’s degree preferred.

Skills/Abilities:

The Ideal Candidate must be detail oriented, self motivated and a team player. Must be able to work independently as well as part of a team. Strong Communication skills are a must.

Licenses/Certificates/Registrations

Valid NYS RN license. Valid NYS Drivers License required.