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Posted: Saturday, February 3, 2018 6:23 PM

**_Position Summary_**
The Health Home Team Leader is responsible for the overall administrative management and clinical supervision of their team, including the appropriate utilization of team members and the quality of client care with an emphasis on a team approach to care coordination. Performs medical care coordination in chronic care management and health promotion to ensure reduced emergency room visits and hospital admissions. Coordinates interdisciplinary care planning and service delivery.
**Formal Education and Job-Related Experience**
* This position requires a minimum formal education of a Masters in Social Work
* LMSW required and a Minimum of one year
* Experience in social or human services working case work with the chronically ill, Pe rsons with HIV/AIDS, the elderly, persons with a history of mental illness, homelessness or chemical dependence or equivalent experience.
**_Essential Functions_**
* Utilizes approved Health Home assessment instruments to prepare initial and ongoing clinical and psychosocial evaluations of mental health, health and other related service needs of identified clients.
* Assesses client medical and behavioral health needs, develops, facilitates, and implements interdisciplinary care plan? Performs semiannual reassessment and care plan update as prescribed by lead Health Home
* Develops a client centered care plan in collaboration with interdisciplinary providers for each individual that addresses clinical and nonclinical healthcare related needs, addressing barriers to goals and services?
* Performs and maintains effective care management for caseload of clients, as assigned, from assessment to discharge. Tracks/ monitors client progress and outcomes, and produces/maintains detailed, accurate and timely case notes.
* Assesses clients support service needs and determines their eligibility for benefit programs? helps securingsocial, financial, and health information within time constraints? Ensures efficient and successful access to and linkage to the full array of necessary physical and behavioral health services.
* Develops inventory of resources that will meet the clients' needs as identified in the assessment process
* and by health home standards. Becomes familiarized with service providers in the health home network.
* Coordinates effective communication between the Team members and all providers involved in the in terdisciplinary care of the client.
* Delegates responsibility of care coordination regarding support service needs to Case Management
* Assistant and/or Care Facilitator depending on level of need
* Facilitates periodic case record reviews and case conferences with all providers serving the client.
* Coordinates interdisciplinary care conferences as needed for stabilization of individual's health and care?
* Works effectively with interdisciplinary team of providers including PCP, substance abuse treatment, residential, hospital discharge planners, etc., to coordinate care delivery between all linked providers and c lient. Case Conferences with all providers involved with the client's medical and other care?
* Assesses treatment compliance and barriers to adherence? ensures that medication reconciliation is
* current?
* Coordinates and provides access to preventive care and health promotion services including mental illness and substance abuse services?
* Maintains updated case records through health home EMR, and coordinates effective electronic communication throughout all provider databases, as needed. Maintains case records in accordance with health home policies/procedures, agency standards and regulatory requirements.
* Participates and consults with Unit Supervisor and/or Clinical Director in case conferences, staff meetings, and discharge planning meetings to determine if client requires an alternate level of care or is appropriate for discharge. Arranges for contact of patient on day of discharge from inpatient services or ER?
* Counsels patient and family members concerning problem resolution, social service delivery? Facilitate client self advocacy and self management? Facilitates communication among and between team members, the patient and family members.
* * *
* At least bi-weekly supervision and more if needed as determined by supervisor.
* RN will be responsible to maintain the team s master tracker to ensure the completion of all Transitional Care DSRIP deliverables is met.
* RN in collaboration with the Transitional Care team will be responsible to develop and cultivate relationships with on site and internal staff to ensure positive work relationships.
* * *
*Program:* Community Case Management Program
*Location:* Brooklyn
*Employment Duration:* Regular Full-Time
*Job Code:* 1887
*Standard Weekly Hours:* 37
Associated topics: alcohol counselor, children services, human services, lcsw, licensed master social worker, sex abuse, sex offender counselor, social services assistant, sociology, substance abuse


• Location: Brooklyn

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