OverviewProvides care management for clients in collaboration with the Wellness case management team consistent with WeCARE and the VNS Home Care policy and requirements of the Wellness Care Management program. Facilitates the coordination of services between the varying providers for clients with complex psychiatric and/or co-morbid medical conditions who are deemed to be temporarily unable to work. Ensures efficient and successful access and linkage to the full array of necessary physical and behavioral health services. Coordinates effective communication between all providers to the ultimate benefit of the patient. Works under close supervision.What We ProvideReferral bonus opportunitiesGenerous paid time off (PTO), starting at 20 days of paid time off and 9 company holidaysHealth insurance plan for you and your loved ones, Medical, Dental, Vision, Life and DisabilityEmployer-matched retirement saving fundsPersonal and financial wellness programs Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care Generous tuition reimbursement for qualifying degreesOpportunities for professional growth and career advancement Internal mobility, CEU credits, and advancement opportunities Interdisciplinary network of colleagues through the VNS Health Social Services Community of Professionals\What You Will DoReviews and utilizes completed medical and mental health assessments from the ResCARE clinical team when initiating the wellness plan for clients on the temporarily unable to work track. . Confirms acuity level of identified client and tailors services plan accordingly.Develops and monitors wellness plan on behalf of clients with untreated or unstable medical and/or mental health conditions adversely affecting the level of employability. Coordinates and integrates a written, coordinated wellness plan in cooperation with the client the client’s family, and/or other providers serving the client.Performs and maintains effective care management for a caseload of clients, as assigned, from wellness initiation to wellness completion. Meets with assigned clients to monitor progress and compliance with the wellness plan. Tracks/ monitors client progress and produces/maintains detailed, accurate and timely case notes. Reviews cases for completeness of documentation.Develops inventory of resources that will meet the clients’ needs as identified in the assessment process. Becomes familiar with service providers in the community where the clients resides in order to mitigate barriers to wellness plan compliance such as transportation, childcare etc.Provides linkage, coordination with, referral to and follow-up with appropriate ongoing service providers. Participates in meetings with service providers to coordinate service and follow up to ensure client’s compliance with and timely completion of the wellness plans and required documentation.Works collaboratively with team members to provide outreach (Via Phone calls, Emails, Texts and Field visits) to clients who have failed to comply with the process of the initiated wellness plan and wellness care management services.Provides information and assistance through advocacy and education to client/family on availability and eligibility of entitlements and community services. Assists with arranging escorts and transportation for clients to appropriate facilities/agencies, as necessary.Participates in initial and ongoing trainings as necessary to maintain basic level of knowledge related to serious physical ailments as defined by HRA. Collaborates with the wellness health team to develop psycho-educational plans for client’s wellness plan process and medication compliance.Maintains updated clients’ case records through the WeCARE wellness care management and HRA platforms, and coordinates effective electronic communication throughout all provider databases, as needed. Maintains case records in accordance with the wellness care management policies/procedures, agency standards and regulatory requirements.Participates and consults with team supervisor in case conferences, staff meetings, and discharge planning meetings to determine if client requires an alternate level of care or is appropriate for discharge.Participates in special projects and performs other duties as assignedQualificationsEducation: Bachelor's Degree in a human services or related field requiredMaster's Degree program in human services or related field preferredWork Experience:Minimum of two years of experience providing direct services to seriously mentally ill patients/clients requiredEffective oral/written/interpersonal communication skills requiredBilingual skills preferred, and may be required as determined by operational needs.Basic computer skills requiredCompensation$23.17 - $28.96 HourlyAbout UsVNS Health is one of the nation’s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives uswe help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.

OverviewConducts assessments and develops client/member centered plans of care. Provides coordination of services between the varying providers for clients / members with complex psychiatric, substance use, and/or co-morbid medical conditions. Ensures access and linkage to the full array of necessary physical and behavioral health services and other community based services to address social determinants of health. Coordinates effective communication between all providers for the ultimate benefit of the client/member. Works under general direction.What We ProvideReferral bonus opportunitiesGenerous paid time off (PTO), starting at 20 days of paid time off and 9 company holidaysHealth insurance plan for you and your loved ones, Medical, Dental, Vision, Life and DisabilityEmployer-matched retirement saving fundsPersonal and financial wellness programs Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care Generous tuition reimbursement for qualifying degreesOpportunities for professional growth and career advancement Internal mobility, CEU credits, and advancement opportunities Interdisciplinary network of colleagues through the VNS Health Social Services Community of ProfessionalsWhat You Will DoUtilizes approved assessments to identify clients/members needs and develop initial and ongoing clinical plan of care.Updates plan at specified intervals, and as needed based on changes in client/member condition or circumstances.Performs and maintains effective care management for assigned caseload of clients/members. Tracks and monitors progress; maintains detailed, accurate and timely progress notes and other documentation.Develops inventory of resources that meet the clients/members needs as identified in the assessment.Provides linkage, coordination with, referral to and follow-up with appropriate service providers and managed care plans. Facilitates periodic case record reviews and case conferences with all providers serving the clients/members.Works collaboratively with team members to provide outreach for and engage resistant/hard to reach clients/members to accept program services.Provides information and assistance through advocacy and education to clients/members and family on availability and eligibility of entitlements and community services. Arranges transportation and accompanies clients/members to appointments as necessary.Participates in initial and ongoing trainings as necessary to maintain and enhance care management skills.Maintains updated case records in program EMR. Maintains case records in accordance with program policies/procedures, VNS Health standards and regulatory requirements.Participates and consults with team supervisor in case conferences, staff meetings, and discharge planning meetings to determine if client/member requires an alternate level of care or is appropriate for dischargeFOR Health Home programs:• Maintains appropriate documentation and standards for all specialized caseloads such as HH+, AOT, Non Medicaid, HARP cases and other special populations.For Children’s Health Home:Completes the Child and Adolescent Needs and Strengths New York (CANS) assessment to determine acuity and to develop initial and ongoing Plan of Care documents.Consults with management and provides reports of suspected abuse and neglect when there is reasonable cause to suspect that a child is a victim of child abuse/neglect.Provides support to legal parent/guardian addressing specific needs relevant to care management of children/adolescents.Maintains appropriate documentation and standards for all specialized caseloads such as waiver transition Home and Community Based Services (HCBS) and other special populations.QualificationsLicenses and Certifications:Valid NYS ID or NYS driver’s license required. NYS Community Mental Health Assessment instrument and HCBS training completion preferredMust complete necessary training to administer NYS Eligibility Assessment for HCBS service in the UAS system within 60 days of start date.Child and Adolescent Needs and Strengths New York (CANS) certification preferredMust complete necessary training to administer the CANS NY assessment in the UAS system within 60 days of start date.Education: Bachelor's Degree in a human services or related field requiredEnrollment/attendance in Master’s degree program in human services or related field preferredWork Experience:Minimum of two years of experience providing direct services to clients/members with Serious Mental Illness (SMI), developmental disabilities, substance use disorders and/or chronic medical conditions client required with a Bachelor’s degree; minimum of one year of experience with a Master’s degree.Effective oral/written/interpersonal communication skills requiredBilingual skills may be required as determined by operational needs.Basic computer skills requiredCompensation$23.17 - $28.96 HourlyAbout UsVNS Health is one of the nation’s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives uswe help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.