Position Purpose: Provides person-centered services to an assigned caseload of adult clients and serves as a liaison between clients and clinics in a way that increases client commitment to their care plans, increases their abilities to manage and reduce their symptoms in the community so that clients' mental health is improved and the use of emergency and inpatient. services is reduced.

Primary Position Responsibilities:

Care Planning and Coordination

• Provides comprehensive assessment and service planning with consumers who have chronic medical problems and/or significant mental illness.


• Builds person-centered relationships with clients by getting to know them and what motivates them, resulting in trusting, positive relationships in which clients experience support and help and demonstrate commitment to their care plans.


• Provides Care Management activities including face-to-face meetings, mailings, electronic communications and telephone calls with consumers, their families/significant others, and various community service providers.


• Manages caseloads that vary from 55-65 persons depending on level of contact needed per client.


• Responds on a timely basis to telephonic, e-mail, or other communications related to consumers, internal correspondence, or outside communications related to the Care Manager position.


• Advocates for clients, monitors their health and medication adherence, arranges for/transport to medical appointments, and connects to entitlements.


• Works independently and at times under pressure, prioritizes caseload, and takes a problem-solving approach to work.

Outreach and Crisis Intervention

• Intervenes when clients are in crisis, evaluating risks and supports, and develops and implements a crisis management plan. Evaluates when crises have resolved and/or are managed and adjusts service levels accordingly.


• Works effectively within a designated BFNC Care Management Team to provide necessary services to all consumers attached to the team to ensure 24 hour, 7 day a week coverage.


• Provides outreach and engagement activities to active and potential consumers to elevate levels of care plan commitment and recruit new clients.


• Links clients to medical, financial, social, rehabilitation and psychiatric services

• Facilitates vocational/educational goal support and recreation/leisure skill development; assists with apartment finding and set-ups and property owner relations.

Documentation, Statistical Tracking and Quality Assurance Activities

• Develops, monitors, and periodically updates a comprehensive, individualized, client centered Plan of Care that will integrate the individual's medical and behavioral health services, rehabilitative, long term care, and social service needs as applicable.


• Maintains audit-ready charts including required assessment, service planning and Contact Notes as required.


• Inputs and retrieves electronic data from various systems including database and web based systems.

KNOWLEDGE AND SKILL REQUIREMENTS

• High School degree with 3 years of experience in a human services or healthcare setting working directly with people. Bachelor's degrees welcome.


• Must have a valid New York State driver's license


• Demonstrated passion for working with people from all backgrounds and ages and providing person-centered care supported by excellent interpersonal and communication skills


• Excellent written and oral communication skills with strong organizational skills


• Fully proficient in Microsoft Office and experience with or ability to master electronic health records


• Must be able to work independently


• Must exhibit a passion for BFNC's vision, mission and values and act as a role model for agency values and responsible practices


• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position


• The job specifications cited in this Job Description are not to be interpreted to be a complete list of all the qualifications and performance expectations needed to perform this job adequately. Management can at its discretion add, drop, or change at any time the duties, responsibilities, and expectations of this job.


• This job description does not constitute an offer of employment, continuous employment, or an employment contract.