AOT Care Coordinator - Bronx, NY, United States - Essen Medical Associates

Description

The AOT care coordinator liaises between the court system, medical system and the community and is responsible for case retention activities, while maintaining a caseload of 15-20 AOT members.

The incumbent partners with the members to become involved in all aspects of their care. The care coordinator delivers quality services to ensure compliance and adherence.

The care coordinator meets with the members on a weekly basis at their residence, medical appointments and or in the community to address specific care plan goals, which include but not limited to addressing medical and psychiatric , behavioral health needs associated to the designated court ordered treatment plan.

In partnership with care team and staff from the Office of Assisted Outpatient Treatment, the AOT

Care Coordinator:
As mandates, in-person visits must be performed at the members' residences or in the community at a convenient location.

Performs essential transitional care coordination services, including pre-release contacts, day-of-release warm handoffs, assessments and service planning, and assists with entitlements, housing, vocational rehabilitation, life skills, and reintegration services.

Connects members to community support services and outpatient health services, including mental health, substance use, behavioral health, harm reduction and medical services.

Documents all encounters and interventions timely and completes initial assessments, reassessments, service care plans, progress notes (using DAP format), and discharge plans.

Attends compulsory training, related to prison re-entry, harm reduction, overdose prevention and behavioral health/criminal justice.

Maintains ongoing communication and partnership with DOCCS/Parole, the Department of Homeless Services (DHS), and the Office of Mental Health (OMH).

Provides care coordination services from strength-based, recovery-oriented, trauma-informed, and culturally appropriate approaches.
Performs other duties as requested by immediate supervisor.

Bachelor's degree in social services, Human services and Social Sciences or, master's degree in social work with license to practice in New York State.

At least six years in the provision of community-based social and case management services.

At least two years of experience in a professional environment providing care coordination or clinically based interventions to individuals involved in the criminal justice systems.

Knowledge of community resources for individuals with serious mental illness, developmental disabilities, or alcoholism or substance abuse.
Professional experience in navigating services for homeless and substance use populations with medically and psychiatrically complex needs.