OverviewProvides care management through a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet member's health needs through communication and available resources, while promoting quality cost-effective outcomes. Maintains members in the most independent living situation possible; ensures consistent care along entire health care continuum by assessing and closely monitoring members' needs and status. Provides care management services and authorizes/ coordinates services within a capitated managed care system. Communicates and collaborates with primary care practitioners, interdisciplinary team and family members. • Assesses, plans and provides intensive and continuous care management across acute, home, and long-term care settings. Develops and negotiates care plans with members, families and physicians.• Assesses a person’s living condition/situation, cultural influences, and functioning to identify the individual’s needs; develops a comprehensive care plan that addresses those needs.• Assesses an enrollee’s eligibility for Program services based on his or her health, medical, financial, legal and psychosocial status, initially and on an ongoing basis.• Plans specific objectives, goals and actions designed to meet the member’s needs as identified in the assessment process that are action-oriented, time-specific and cost effective.• Implements specific care management activities and or interventions that lead to accomplishing the goals set forth in the plan of care.• Coordinates, facilitates and arranges for long term care services in the home and community-based sites, such as adult day care, nursing homes, rehab facilities, etc. Arranges for on-going nursing care, service authorization and periodic assessment.• Collaborates and negotiates with interdisciplinary teams, health care providers, family members, and third party payors, as applicable, across all health settings to ensure optimum delivery and coordination of services to members.• Monitors care management activities, services, and members’ responses to interventions, to determine the effectiveness of the plan of care and the utilization of services.• Evaluates the effectiveness of the plan of care in reaching desired outcomes and goals; makes modifications or changes in the plan of care as needed.• Identifies trends and needs of groups in the community and plans interventions based on these identified needs.• Provides care management services across sites and collaborates with appropriate facility discharge planner and/or HCC when members are transitioned between settings.• Manages expenditures to ensure effective use of covered services within a capitated rate. Fiscally responsible in providing services based on members’ needs.• Provides social work services in accordance with NASW code of ethics, VNS Health policies, practices, and procedures.• Participates in outreach activities to promote knowledge of the Program and its services and to coordinate Program activities with outside community agencies and health care providers (e.g., community health screening, In Services).• Participates in the development of programs to meet the specialized needs of this selected patient population.• Documents services in accordance with Health Plans Community Care standards and Managed Long Term Care (MLTC) and Licensed Home Care Services Agency (LHCSA) regulations.• For Palliative Care Only:• Understands and supports ability to cope with patients’ illness. Provides emotional, spiritual, and practical support for patient and family • Reviews tools, programs and other resources for potential serious illness program appropriate patients and make referral as necessary.• Provides education to patients and their families to better understand patients’ disease and diagnosis.• Facilitates open discussion about treatment choices for patient’s illness (including difficult and complex choices) and management of symptoms.• Provides expertise in treatment of pain and other symptoms.• Participates in special projects and performs other duties as assigned. QualificationsLicenses and Certifications:License and current registration to practice as a Licensed Social Worker in New York State preferred Education: Master's Degree in Social Work required Case Management Certification preferredWork Experience:Minimum of three years of Social Work experience required.Minimum of two years in a case management and/or community based environment preferred.Bilingual skills may be required, as determined by operational needs.Clinical expertise in geriatrics, Long Term care and Managed care experience preferred Pay RangeUSD $70,200.00 - USD $87,700.00 /Yr. About UsVNS Health is one of the nation’s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.

OverviewLicensed Behavioral Health Clinicians provide supportive counseling, advocacy, education, and care management to help patients and their families navigate mental illness, access community resources, and manage symptoms to help them remain safely in the community This is a senior, master’s level, licensed social services role that provides direct care as part of a team. Join us in building on our 130-year history and become a part of the Future of Care that is strengthening communities with high quality, integrated behavioral health programs. VNS Health Behavioral Health team members provide vital client-centered behavioral health care to New Yorkers most in need, across all stages of life and mental well-being. We deliver care wherever our clients are, including outpatient clinics, clients’ homes, and the community. Our short- and long-term service models include acute, transitional, and intensive care management programs that impact the most vulnerable populations, from children, to adolescents, to aging adults. As part of our fast-growing Behavioral Health team, you’ll have an opportunity to develop and advance your skills, whether you’re early in your career or an experienced professional. What We ProvideAttractive sign-on bonus and referral bonus opportunitiesGenerous paid time off (PTO), starting at 30 days of paid time off and 9 company holidaysHealth insurance plan for you and your loved ones, Medical, Dental, Vision, Life and DisabilityEmployer-matched retirement saving fundsPersonal and financial wellness programs Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care Generous tuition reimbursement for qualifying degreesOpportunities for professional growth and career advancement Internal mobility, CEU credits, and advancement opportunities Interdisciplinary network of colleagues through the VNS Health Social Services Community of ProfessionalsWhat You Will DoUtilizes approved assessments to identify clients/members needs and family needs; develops initial and ongoing clinical plan of care. Updates plan at specified intervals, and as needed based on changes in client/member condition or circumstancesPerforms and maintains effective care management for assigned caseload of clients/members. Leads the care coordination for complex psychiatric clinical cases. Tracks and monitors progress; maintains detailed,accurate and timely progress notes and other documentationProvides supportive counseling and/or supportive therapy as well as ongoing mental health servicesCollaborates and refers to appropriate agencies as required. Addresses any client/member concerns to ensure satisfaction with overall services provided and uses motivational interviewing techniques to foster behavioral changesDevelops inventory of resources that meet the clients/members needs as identified in the assessmentProvides linkage, coordination with, referral to and follow-up with appropriate service providers and managedcare plans. Facilitates periodic case record reviews and case conferences with all providers serving theclients/members Provides information and assistance through advocacy and education to clients/members and family onavailability and eligibility of entitlements and community services. Arranges transportation and accompaniesclients/members to appointments as necessaryAssists clients/members and/or families in the development of a sustainable network of community-basedsupports, utilizing identified strengths and tools designed to prevent future participant crises and/or reducethe negative impact if a crisis does occurParticipates in initial and ongoing trainings as necessary to maintain and enhance clinical and professionalskillsMaintains updated case records in program EMR. Maintains case records in accordance with programpolicies/procedures, VNS Health standards and regulatory requirementsParticipates and consults with team supervisor in case conferences, staff meetings, utilization review anddischarge planning meetings to determine if client/member requires an alternate level of care or isappropriate fordischargeParticipates in 24/7 on-call coverage schedule and performs on-call duties, as requiredActs as liaison with other community agenciesProvides short term counseling (coping skills, trauma informed, decision making) and Risk HealthAssessment/Safety PlanningCollects and reports data, as required while adhering to productivity standardsLeads and participates in “Network Meetings” with client, client/ member’s personal support network andother team members using the Open Dialogue Model QualificationsMaster's Degree in Social Work, Psychology, Mental Health Counseling, Family Therapy or related degreeMinimum of two years of mental health work experience providing direct services to clients/members with Serious Mental Illness (SMI), developmental disabilities, substance use disorders and/or chronic medical conditions requiredEffective oral/written/interpersonal communication skills requiredBilingual skills may be required as determined by operational needsLicense and current registration to practice as a Mental Health Counselor, Marriage and Family Therapist , Social Worker, Clinical Social Worker or related license in New York State Pay RangeUSD $63,800.00 - USD $79,800.00 /Yr. About UsVNS Health is one of the nation’s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.

OverviewLicensed Social Workers provide supportive holistic social work services to patients and families during life’s most difficult moments ensuring a seamless integration with the healthcare team’s efforts. You’ll work in tandem with healthcare professionals, upholding quality standards and policies to provide exceptional support. You’ll tailor services to meet the unique needs of each patient and family, fostering an environment of care and understanding. This is an experienced, master’s level, licensed social services role that provides direct care as part of a team. Join us in building on our 130-year history and becoming a part of the Future of Care that is strengthening communities with high quality, integrated social work programs.SCHEDULE:Part-TimeSaturday & Sunday, 11:00am-7:00pmMonday 4:30pm-12:30am What We Provide Referral bonus opportunitiesGenerous paid time off (PTO), starting at 30 days of paid time off and 9 company holidaysHealth insurance plan for you and your loved ones, Medical, Dental, Vision, Life and DisabilityEmployer-matched 401k retirement saving program and opportunity for both pre- and post-tax contributionsPersonal and financial wellness programs Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care and commuter transit program Generous tuition reimbursement for qualifying degreesOpportunities for professional growth, career advancement and CEU creditsWhat You Will DoAssess clients and family psychosocial status, social work needs, and living conditions utilizing professional knowledge, skills of observations and interviewing skills.Establish the social work component of the patient/family plan of care based on goals mutually acceptable to the client, family, and significant others. Make referrals to other community services, as necessary.Provide psychosocial work services to patient and family, including short-term individual counseling, community resource planning, and crisis intervention. Responds to emergent psychosocial patient and family needs, as requested.Travel to patients’ homes and/or other facilities with varying environments to deliver patient careInitiate and maintain verbal and written communication according to VNS Home Care policy, including the timely preparation of clinical and progress notes, to ensure optimal quality care. QualificationsLicenses and Certifications:Current registration to practice as a Licensed Social Worker or Licensed Master’s Social Worker (LMSW) in New York State, requiredValid driver's license or NYS Non-Driver photo ID card, may be required as determined by operational/regional needsEducation: Master’s degree in social work after successfully completing a prescribed course of study at a graduate school of Social Work accredited by the Council on Social Work Education and the Education Dept. and who is certified or licensed by the Education Dept to practice Social Work in New York State, requiredWork Experience:Minimum one year of social work experience in a health care setting, requiredBilingual skills may be required, as determined by operational needsFor Gender Affirmation Program only:Experience with the LGBTQ+ populations, preferred Pay RangeUSD $63,800.00 - USD $79,800.00 /Yr. About UsVNS Health is one of the nation’s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.