St. Mary’s Healthcare has been named a 2025 Times Union Top Workplace. We are the first acute care hospital in the Capital Region to earn the distinction since the Times Union launched the recognition program 14 years ago. Job Requisition: REQ3758 Employment Type: Full-Time Shift: Days Hours Per Week: 40 hours Hiring Range: $20.62 -$27.59 The actual compensation for this position will be determined based on experience and other factors permitted by law. Responsibilities: + Work closely with the interdisciplinary team members including but not limited to PCP, mental health providers, schools, specialty providers, and MCO’s to develop and maintain ongoing coordination of the plan of care. + Ensure that there is consistent coordination and communication between the team members. + Complete assessments (comprehensive, CANS-NY, HARP, HCBS) and utilize results to develop and complete person centered plan of care for members on the caseload. Help to identify barriers and/or gaps in care and ways to overcome these barriers to help members achieve treatment goals when possible. + Actively participate in discharge planning and care transition activities resulting from ER visits and inpatient stays. + Assist members with connecting to resources in the community to help with barriers to care, social determinants of health, transportation, and/or chronic medical or mental health diagnoses. + Provide care coordination and/or core services to members monthly as deemed necessary. + Maintain timely documentation requirements to ensure DOH regulations and standards for each member assigned to caseload. + Report any suspected abuse as outlined as a mandated reporter. Additional Responsibilities: + Other duties as assigned. Complexity of Work: • Within scope of job, requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment. Personal Protective Equipment: • Follows Standard Precautions using personal protective equipment as required. Education, Training & Experience: + Master's degree in one (1) of the qualifying fields and one (1) year experience OR + Bachelor’s degree in one of the qualifying fields and two (2) years’ experience OR + Credentialed alcoholism and Substance Abuse Counselor (CASAC) and two (2) years’ experience OR + Bachelor's degree or higher in any field with either three (3) years of experience or two (2) years’ experience as a Health Home Care Manager serving the SMI or SED population. Experience must consist of: Providing direct services to people with serious mental illness, developmental disabilities, alcoholism or substance abuse, and/or children with SED OR + Linking individuals with SMI, children with SED, developmental disabilities, alcoholism, or substance abuse to a broad range of services essential to successful living in a community setting (medical, psychiatric, social, educational, legal, housing and financial services). Certifications / Licensure: + Valid NYS Drivers License required Required Skills and Attributes: + Ability to organize and establish day-to-day priorities while using critical thinking skills in all aspects of the job. + Must be able to multitask while remaining professional, focused, composed and positive. + Excellent customer service skills  Displays integrity, friendliness, and compassion. + Must be able to establish an appropriate and effective rapport with others. + Demonstrates flexibility + Takes initiative + Able to work in a fast-paced environment + Embraces new opportunities to grow both personally and professionally. + Effective critical thinking and problem-solving skills.  Proficient with various Microsoft Office products (Word and Excel). + Strong organizational skills. + Effective interpersonal skills. + Ability to take and follow direction in a positive and appropriate manner. + Ability to work as part of a team and independently. Must be able to demonstrate effective and appropriate written and oral communication skills.  Must be able to speak, read, write and follow instructions in English.