Purpose: To provide patient-centered, high quality care management services in a timely manner to clients with complex chronic conditions by navigating systems such as primary medical, specialty and behavioral health care, as well as social services. Key Functions: • Provides comprehensive care management services including: outreach and engagement; assessment/reassessment; development and implementation of initial and revised individualized care plans; consult with primary care physician, and other care provider(s); identify crisis intervention plan . • Provides care coordination and health promotion including: collaborate with service providers and health plans to obtain medically necessary care, share crisis intervention(s) and emergency info; linkage to services to support care and treatment goals/plans; patient education ; self-help recovery and selfmanagement; case reviews; advocate for services and assist with scheduling; collaborate with providers to ensure service delivery; monitor, support, accompany (as indicated) patient to/with scheduled appointments; crisis intervention . • Provides comprehensive transitional care including: follow up on notice of ER/hospital/residential/rehab setting admission and discharge; facilitate discharge planning with ER/hospital/residential/rehab setting staff to a safe location with care needs in place; notify service providers of admission/discharge and follow appointment needs; link with community supports; post discharge follow up. • Provide member and family support including: care planning with patient/family; patient/family consultation and education around health care needs; patient/family meetings; patient/family referral to peer supports, support groups, social services and other programs as indicated; collaborate with community providers to support service utilization based on patient/family need. • Provide referral to community and social support services including: identifying and linking to community supports as needed; assure and assist with access to medical, behavioral health, substance abuse and other community based services as needed. 2 • Timely and comprehensive completion of documentation including notes, assessments, tracking tools, etc. • Adhere to Company policies and procedures to include being aware of the importance of Corporate Compliance Policies and the Code of Conduct. Staff is responsible for maintaining required certifications and licenses. • Attends necessary trainings and inservices, participates in department and agency meetings as required. • Performs other related duties as assigned by supervisor/director. Values: Demonstrates the organization’s values • Customer Service • Communications • Continuous Improvement • Collaboration/Teamwork • Accountability Education, Experience, Skills and/or Licensing/Certification Required: An Associate’s degree in Human Services field AND 4 years of experience OR Bachelor’s degree AND 2 years of experience in public or community mental health settings serving low income and culturally diverse populations. Computer literacy required. Valid New York State driver’s license with approved driving record and access to a reliable vehicle with proof of insurance for vehicle is required. Supervisory Responsibility: • None

Minimum Salary: 18.00 Maximum Salary: 22.00 Salary Unit: Hourly