STATEMENT OF THE JOB
The DOHMH Team Supervisor of the Non-Medicaid Care Coordination DOHMH program, is responsible for supervisory oversight operations in CCNS’s Care Coordination Program under the Department of Health and Mental Hygiene; a setting of up to 100 clients. The DOHMH Team Supervisor oversees a Care Coordination team made up of three BA level Care Coordinators, and a Peer Coordinator. The scope of work requires the program to maintain & service a census of a minimum of 74 clients, but can increase up to 100. It is the DOHMH Team Supervisor has the responsibility to focus the team’s activities on the integration and coordination of physical health and mental health needs internally and with affiliated agencies.
The DOHMH Team Supervisor will direct and oversee team’s efforts for client-centered care first and foremost while maintaining the additional goal of reducing avoidable health care costs, specifically preventable hospital admissions/readmissions and avoidable emergency room visits, and improving client’s outcomes by addressing primary medical, specialist and behavioral health care through contractual arrangements with appropriate service providers of comprehensive, integrated services.
The DOHMH Team Supervisor is also responsible for ensuring that team’s care coordination activities are person and family centered, culturally competent and linguistically capable.They must also ensure complete documentation through electronic health record keeping and have the ability to interface with various websites as required by the DOHMH Contract.
DUTIES AND RESPONSIBILITIES
- Demonstrate commitment to the vision of care coordination and motivate team staff to achieve strategic priorities of the DOHMH contract.
-
Accountable for team’s ability to engage and retain clients in care by implementing evidence-based practices including Motivational Interviewing techniques, coordinating continuous provision of services, supporting adherence to treatment recommendations, and monitoring and evaluating members’ needs.
-
Oversee the development and follow-up/updates to clients’ plan of care and ensure it is accessible to the interdisciplinary team of providers for service integration and collaboration.
-
Direct and coordinate staff efforts for the promotion of evidence based wellness and prevention activities of the team for linking clients with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other medical services based on individual physical needs and preferences.
-
Monitor outreach and engagement activities of the team, which will support engaging the referred clients in their own care and promote continuity of care.
-
Regularly assesses the team’s caseload needs and goals and clearly identify reported progress in meeting goals by individual clients as well as compliance with recommended treatments.Ensure fluidity of cases so that each client receives the level of care they require, when required.
-
MonitorCare Coordination team efforts to ensure clients have needed services, whichmay include but are not limited to,acute, primary, and preventive medical care, Home Health Care, Chemical Dependency Services, Behavioral Health Services, community social support services, housing, State and federal entitlements
-
Coordinate team activities to provide timely access to high-quality health care services for outpatient care, community resources, transitional care from hospital to home or other settings (such as participation in discharge planning; incarceration, various levels of on –going medical care).
-
Conduct regular case & chart reviews. Provide logistical support for regular care team case conferences.
-
Provide case conference review and guidance with team for identification of potential barriers to care and resolutions to those barriers.
-
Lead team meeting to assure that communication is fostered between the dedicated Care Coordinators, clients and their providers.
-
Supervise the quality of Care Coordinators contacts with clients - phone contacts, observe home visits and face to face meetings. Directly observe and review coordination of care for a higher risk cases.
-
Coordinate team’s activities in identifying the primary care physician and multidisciplinary teams of medical, mental health, chemical dependency treatment providers, social workers, nurse’s nutritionists/dieticians, pharmacists, outreach workers including peer specialists and other care providers to assure that clients receive needed medical, behavioral, and social services in accordance with a plan of care.
-
Ensure care coordinators meets CAIRS database reporting requirements for all assessments and reporting per DOHMH standards and OPRE standards.
-
Conduct field visits to clients, family providers, and participate in case conferences. Interface with government entities as needed. Carry caseload of clients to ensure continuity of care as needed.
-
Ensure care coordinators conduct a minimum of 2 face to face visits to each client monthly, and complete progress notes documentation, care planning and necessary assessments. Ensure care coordinators provide 4 face to face visits to AOT clients monthly, including collateral contacts and weekly reporting into the AOT portal.
-
Complete AOT training and ensure all newly hired staff complete training within 30-days of hire.
-
Assist with community enrollments and communication with DOHMH as needed for such.
-
Ensure implementation of a continuous quality improvement plan for the team. Collects and reports on data that permits an evaluation of increased coordination of care and chronic disease management- maintains hospitalization log and reports on health outcomes.
-
Conduct workshops, trainings and regular supervision for the team staff.
-
Evaluate staff performance and develop performance improvement plan, as needed.
-
Responsible for overseeing the team maintaining the security of all data files and employment ofapproved methods of data encryption to prevent theft of personally identifiable information up to HIPAA standards.
-
Ensure program remains in compliance per OPRE-DOHMH standards, and is audit ready.
-
Provide and/or contribute to the annual performance evaluations of staff including the documentation of disciplinary actions and the development of professional goals.
- Collaborate with administration in the identification of developing marketing strategies.
-
Participate in committees as directed.
-
Provide direct member coverage as needed.
-
Cooperate with any and all investigations conducted by the Agency, funding sources and any other authorized agencies/entities.
-
Reports to Integrated Health & Wellness Services Administration and/or Agency Administration issues that may have a negative impact on the reputation of the Agency, client and/or staff welfare or any corporate compliance issues.
-
Performs other related duties as requested or assigned by agency management.
SPECIFICATIONS FOR EDUCATION/LICENSES/CERTIFICATIONS
-
Master’s Degree in Social Work, Nursing, Public Health or other related social service or health profession
-
NYS RN, NP, LMSW/LCSW CASAC, License or a Licensed Psychologist preferred.
SPECIFICATIONS FOR EXPERIENCE AND TRAINING
-
Excellent computer skills are necessary.
-
The position requires a combination of skills in the areas of crisis assessment, clinical intervention, time management, organizational and management skills.
-
Knowledge of the community medical resources and their financial requirements.
-
Good oral and written communication skills.
SPECIFICATIONS FOR PHYSICAL REQUIREMENTS
-
Able to utilize technology conferencing tools including audio, video and /or web deployed solutions and accountable for hand-held devices (I Phone, Blackberry, I Pad, Tablets, Laptops, etc.)
-
Work schedule includes holiday coverage to accommodate the coverage needs of the program when required. 24 hours/seven days a week availability to provide information and emergency consultation services and to coordinates staff coverage.
-
Ability to work flexible hours and days – including weekends/evenings/holidays according to needs of a 24/7 program.
-
Ability to travel in the community and use public transportation.
-
Frequent sitting to write reports and when meeting with clients.
-
Ability to read printed materials and computer screens.
