About Long Island Select Healthcare, Inc. Long Island Select Healthcare Inc. (LISH) is a comprehensive network of community health centers.We are a Federally Qualified Health Center (FQHC) that provides Article 16 and 28 clinic services at 8 locations across Suffolk County, New York.We are a multi-specialty healthcare provider caring for our community through Primary and Specialty Medical Care, Dental, Behavioral Health, Audiology, Physical Therapy, Occupational Therapy and Speech Language Pathology. We currently provide care to over 7,000 patients and have an annual operating revenue of $22m. LISH is a Forward-Thinking, Community-Oriented Organization! NYS Patient-Centered Medical Home Chronic Care Management Program Telemedicine & Virtual Care Services Program Integrated Primary & Behavioral Healthcare
- Create an individual based care plan. The care plan will be developed based on the information obtained from a comprehensive health risk assessment used to identify the enrollee's physical, mental health, chemical dependency and social service needs.
- Accountable for engaging and retaining health home enrollees in care, as well as coordinating and arranging for the provision of services, supporting adherence to treatment recommendations, and monitoring and evaluating the enrollee's needs. The individualized plan of care will identify all the services necessary to meet goals needed for care management of the enrollee such as prevention, wellness, medical treatment by specialists and behavioral health providers, transition of care from provider to provider, and social and community services where appropriate.
- Provide comprehensive transitional care from inpatient to other setting. Schedule appropriate follow-up appointments with after care settings and ensure the individual remains in treatment.
- Provide Individualand family support.
- Provide outreach services by telephone and face to face contact to individuals who are not yet enrolled in Home Health services and consent them to the respective Health Home.
- Engage patients in care by phone, letter, HIT and community outreach at least once per quarter.
- Use health information technology to link services, document care management activities, and data collection for quality indicator measurement
- Create integrated care plan with patient and/or caregiver. care plan will include physical, mental health, and social service needs.
- Provide education on preventive care
- Review and upload pertinent medical/behavioral information through the RHIO
- Document care plan, all contacts with client and follow up in EMR application
- Comply with agency Compliance Plan and False Claims Policy by preventing, detecting and reporting any potential healthcare abuse and fraud. Report any potential non-compliance and comply with all other federal, state and local regulations applicable to this job description.
- Utilize all agency based IT applications pertaining to this job description in a proficient manner.
- Remain current on changing developments individual field expertise.
- Serves as an advocate for the patients, and act as a liaison between the patients and community agencies.
- Participates in department staff meetings as requested.
- Submit timely reports of services, activities and other reports required by the supervisor and department director.
- Works with patient navigators to coordinator and/or generate incoming referrals.
- Performs other duties as assigned
Education and/or Experience Certified Medical Assistant or Licensed Practical Nurse(LPN) required. Care Coordination experience preferred. 2 to 5 years of experience serving people with medical illness and/or developmental disabilities preferred. Valid NYS Driver's License. If LPN, Active and Unrestricted Licensed by NYS Office of Professions is mandatory.Must have behavioral health experience. Salary range ($51,000-$61,000) Position is a hybrid role.