Provides care coordination and non-clinical support functions to PHP participants in accordance with PHPs’ model of care as well as CMS, NYSDOH and OPWDD contractual agreements. QIDP level member of a two-person team responsible for full continuum of care coordination activities, including assessments, care and service planning, advocacy, coordination of care and ongoing monitoring of Participants enrolled in PHP.
Duties and Responsibilities:
- Practice and promote PHPs’ mission and values; and •Utilize a person-centered approach and support members to be as self-directed as possible; and •Serve as the primary point of contact for PHP participants; and
- Complete assessments and other participant documents, including IAM, Level of Care, Comprehensive Emergency Plans, Environmental Assessments, and Caregiver Adequacy in alignment with PHP Policies and Procedures; and •Lead IDT meetings and complete participant Life Plans in alignment with PHP Policies and Procedures; and •Ensure integration of all needed and preferred supports and services (i.e., medical, behavioral, social, habilitation, dental, psychosocial, and community-based, and facility-based long-term supports, and services, etc.); and
- Monitor effectiveness of care and service plans through member/IDT contact in alignment with PHP Policies and Procedures; and •Link and refer participants to service providers and activities, including community resources; and maintaining/applying for benefits and entitlements such as Medicaid, Food Stamps, HEAP, etc.; and •Assist individuals to resolve problems in living such as housing, utilities, the judicial system, and general safety; and
- Responsible for advocating for and with an individual to ensure informed decision making, informed consent, and guardianship that is appropriately carried out; and • Report abuse or neglect immediately when observed or reported; and • Alert Clinical Team Leader regarding any emerging physical or behavioral health issues; and
- Coordinate/schedule all participant meetings, appointments, and transportation as needed; and • Provide visits to participants’ homes as needed; and • Provide assistance in orientation and education to participants, families, IDT and other providers and stakeholders; and
- Adhere to all required timeframes for participant telephonic and in person contacts, assessments, care management notes, life plan meetings and life plan completions; and • Provide all verbal, written and electronic communication with participants/caregivers/families, IDT, providers, and vendors in a timely manner and accordingly document; and • Provide timely preparation and completion of all data entry, data collection, report production; and
- Maintain participant documents in secure electronic record system and meet all confidentiality requirements; and • Adhere to all requirements set forth in the Willowbrook Permanent Injunction as appropriate; and
- Complete training necessary to acquire and demonstrate knowledge of the following areas necessary to fully support participants: Physical health, aging and loss, appropriate community support services, frequently used medications and their potential negative side-effects, depression, challenging behaviors, Alzheimer’s disease and other disease-related dementias, behavioral health, and issues related to accessing and using durable medical equipment, as appropriate; and
- Flexibility with work schedule, including evening and weekend hours may be required as needed; and • Perform all other duties as assigned.
- Must meet the requirements of a Qualified Intellectual Disability Professional (QIDP) as defined by New York State; and
- Excellent interpersonal, communication and organizational skills along with attention to detail required; and
- Working knowledge of Microsoft Word and Excel in a windows environment required; and
- Excellent follow-up and problem resolution skills also required; and
- Proficiency with health-related computer applications desired; and
- Valid Driver’s License to travel within NYS preferred; and
- Must be able to travel as necessary and adhere to PHP’s travel polices; and
- Ability to work remotely if needed while adhering to HIPAA requirements.
Requirements of All Positions:
- All employees shall meet PHP’s Compliance and Privacy Regulations, and attend at a minimum of one (1) hour of Compliance and Privacy educational training annually;
- All employees shall master PHP’s Model of Care and complete all training requirements within the first thirty (30) days of employment and annually thereafter, or as required by state and federal regulations;
- All employees are required to maintain confidentiality, protect privacy, comply with Protected Health Information regulations, and report violations;
- Perform functions as they relate to “Improving Health Care Quality” as defined in the National Association of Insurance Commissioners Supplemental Health Care Exhibit that:
1. Improve health outcomes;
2. Prevent hospital readmission;
3. Improve patient safety and reduce medical errors, and
4. Provide wellness and health promotion activities.
Physical Demands and Work Environment:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel utilize objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, kneel, crouch or crawl.
The employee must occasionally lift and/or move up to 25 pounds, and infrequently up to 50 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus. The noise level in the work environment is usually moderate.
Equal Opportunity Employer