- Provide integrated care services to the client population at the clinic as indicated by the OASAS, OMH CCBHC expansion scope of practice
- Provide clients with services in the filed as required
- Participate in grant related workshops and trainings
- Use the grant portals; SPARS to enter any grant required data in terms of service provision, clinical indicators
- Develops and conducts group, individual and family counseling on a scheduled basis to caseload clients
- Meet assigned productivity goals
- Be on a call rotating schedule
- Complete community, outreach work in the field
- Provide care management services to patients living with chronic illnesses and their families/support systems through ensuring access to care, engagement in care coordination of care to obtain the full range of needed services.
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- Gather enrollment consents, RHIO consents, and complete screening, baseline-risk assessments, reassessments, plan of care, plan of care updates and notes in accordance with OASAS and departmental policies.
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- Demonstrate the ability to clearly articulate, verbally and in writing, the aims and goals of OASAS to potential patients, community members and staff.
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- Participate in quality improvement activities, projects and reviews in collaboration with the Case Manager.
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- Complete daily, weekly, monthly, or other periodic requests for narrative or quantitative data reports for program review
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- Prioritize the homeless population through identification of new sources of potential patients, onsite meetings with patients at their shelter and conduct outreach and engagement presentations.
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- Meet regularly with supervisor and attend staff meetings and case conferences. Be prepared to discuss case management and operational issues impacting performance and program operations.
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- Complete and submit daily activity log in accordance with departmental policies.
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- Ensure patient is attending scheduled medical and social service visits through building relationships with patients and providers. Coordinate and schedule appointments with Social Worker and Medical/Mental Health providers. Routine calls should be made to internal and external providers before and after visits to follow up and provide necessary support to the patients.
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- At a minimum, maintain four contacts with each client or at a greater frequency as indicated by the risk stratification and plan of care.
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- Access and respond per agency guidelines to client complaints of grievances
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- Conduct outreach and engagement in accordance with OASAS's policies via phone, electronic methods, and letter and or field work to client/collateral/provider to engage clients or strengthen connectivity.
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- Help maintain health and wellness and prevent secondary disease complications through provision of health information, support plan of care, and coaching.
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- Promote and expand linkage development in all areas related to patient care including social determinants (e.g. housing, employment) and monitor the effectiveness of linkages with other service providers via phone, face to face meetings of formal case conferences.
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- Communicate effectively with Supervisor in identifying strengths, weakness and opportunities of program operations
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- Ensure community-follow up to engage the client in care; promote compliance with medical appointments and encourages client self-sufficiency and empowerment.
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- Identify and attend training for professional development and attend departmental in-service meetings as required
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