The position works for Crouse Medical Practice, which is the outpatient medical offices affiliated with Crouse Hopsital.

JOB SUMMARY:

The RN Care Coordinator, Mental Health will assess socio-economic and mental health needs contributing to health issues, identify appropriate interventions, and develop and implement a patient-centered goal and care plan; collaborate with appropriate community resource providers to support care plan; collaborate with the patient’s medical team; act as a resource to the population health department and educate patients, support systems and staff; support patient care management and function as a contact for patients, support systems and staff; assist patients in navigating the health and community resource systems. This is a remote position. The successful candidate must live in Central New York.

RESPONSIBILITIES:

• Assess socio-economic needs contributing to health issues, identify appropriate interventions, and develop and implement a patient-centered goal and care plan.

• Identify mental health needs contributing to health issues, identify appropriate interventions, and develop and implement a patient-centered goal and care plan.  Work collaboratively with the population health psychiatrist.

• Identify appropriate community resource providers to support care plan and facilitate patient connections.  Track community-provided interventions and their contribution to the patient-centered care plan.  Collaborate to implement the patient-centered care plan.

• Collaborate with the patient’s primary care and mental health providers, and their clinical teams.

• Analyze family, caregiver and “trusted other” relationships and incorporate into care plan as appropriate.

• Addresses guardianship, level of care, transfer to assisted living or long-term care, medical decision-making, end of life and complex family issues.

• Educates patients, families, caregivers and “trusted others” to support the patient-centered care plan.

• Acts as a resource to the population health department to advise staff on local, state and federal programs, or other community resources or regulations related to social issues. 

• Assist in developing and implementing population health initiatives.

• Determine and manage outcomes, ensure continuity of care through planning, utilization of resources and analysis of variances.

• Support patient self-management of disease and behavior modification interventions.

• Function as a contact person for patient, family, health care team members, community resources and employees as necessary.

• Bill as appropriate for care management services and educate the patient as appropriate.

• Assist the patient in navigating the health care system and community resources.

• Promote clear communication among care team and treating clinicians by ensuring awareness regarding patient care plans.

• Ensure adherence to clinic and departmental policies and procedures.  Patient care assignment will include adult and geriatric age groups.

• Initiate patient and family conferences as needed.

MINIMUM REQUIREMENTS:

1. EDUCATION/CERTIFICATION/LICENSURE:
   1. Current New York State RN license
2. EXPERIENCE:
   1. REQUIRED:
      1. Minimum of 2 years of experience as an RN with mental health focus.
      2. Experience in coordinating care for patients across the care continuum, including home-based, primary and specialty care and long term care.
      3. Experience in establishing working relationships with community service partners and medical teams.
      4. Knowledge of provider community and community resources in the Syracuse NY/CNY areas.
      5. Comprehensive knowledge of insurance company principles and outpatient delivery systems.
      6. Highly organized and well-developed oral and written skills
      7. Demonstrates sound judgment, decision-making, and problem-solving skills
      8. Able to maintain confidentiality with all aspects of information in accordance with Practice, State and Federal regulations
      9. Confidence to advocate and communicate to other community health care organizations and personnel on behalf of patients.
      10. Self-disciplined, energetic, passionate, and innovative.
3. 2. PREFERRED:
      1. Minimum 5 years clinical experience
      2. Experience working in primary and long term care with adult patients
4. SKILLS/PROFICIENCIES:
   1. Excellent communication and teaching skills
   2. Self-disciplined, energetic, passionate and innovative
   3. Demonstrated commitment to collaboration with providers and their clinical teams to enhance patient self-management
   4. Diligent attention to accurate recording of patient information
   5. Uses sound judgment, problem-solving, patience, flexibility and openness when working with patients, families and trusted others.