Department: Health Care Management

Program Description

Care Coordination is a service model whereby all of an individual’s caregivers communicate and interface so that the patient’s needs are addressed in a comprehensive manner. This is done primarily through a “Care Coordinator” who oversees and provides access to all services an individual needs to assure that they receive everything necessary to stay healthy, out of the emergency room and out of the hospital.

The Care Coordinator is responsible for the overall provision and coordination of services to their assigned caseload (caseloads will be determined by children’s acuity level).  The Care Coordinator guides program enrollees and their caregivers through the health care system by assisting with access, developing relationships with service providers, and tracking interventions and outcomes.

Major Duties & Responsibilities

  • Obtains required enrollment consents from the individual or legal guardian
  • Completes initial and ongoing needs assessments (Child and Adolescent Needs and Strengths; CANS) to determine the individual’s most appropriate level of care coordination.
  • Responsible for the overall management of the patient’s Individualized Plan of Care.  Through the creation of an Individual Plan of Care the Care Coordinator is able to:
  1. Coordinate the enrollee’s provision of services
  2. Support adherence to treatment recommendations
  3. Monitor and evaluate a patient’s needs, including prevention, wellness, medical, behavioral health treatment, care transitions, and social and community services where appropriate.
  • Meets documentation requirements in a timely and accurate manner by effectively utilizing designated Care Coordinator Portal (Medicaid Analytics Performance Portal; MAPP) and Electronic Health Records (EHRs) as needed
  • Maintains required contact with participant and their families and conducts face-to-face support team and/or family meetings as required
  • Functions as an advocate for clients within the agency and with external service providers
  • Promotes wellness and prevention by linking enrollees with resources and services based on their individual needs and preferences
  • Effectively communicates and shares information with the individual and their families and other caregivers with appropriate consideration for language, literacy and cultural preferences.
  • Participates in care planning meetings/conferences as an interdisciplinary team member to effectively provide/coordinate comprehensive and holistic care
  • Identifies available community-based resources and actively manages appropriate referrals, access, engagement, follow-up and coordination of services
  • In the event of hospital admissions, actively engages in the discharge planning process ensuring that the patient has all recommended post discharge services in place prior to discharge
  • Arranging appointments, transportation, and interpreter services when needed
  • Accompany the child to appointments as needed
  • Conducting follow-up activities to ensure appointments are kept.
  • Attends and participates in ongoing staff development trainings to enhance skills needed to effectively meet the demands of the Care Coordinator position
  • Other duties as assigned as the program is implemented and develops
  • Preferred Qualifications:
    • A Master’s Degree with one year of relevant experience or
    • Registered Nurse with two years of relevant experience
  • Minimum Qualifications:
    • Bachelors of Arts or Science with two years of relevant experience

In addition the candidate must demonstrate the following:

  • Working knowledge of the provision of health care in a variety of settings.
  • Ability to work directly with a diverse population consisting of Severely Emotionally Disturbed (SED), Medically Fragile (Med F), Developmentally Disabled (DD), Division of Juvenile Justice
  • Computer Literacy (specifically Microsoft Word, Excel)
  • Excellent telephone and interpersonal skills
  • Ability to work directly with a diverse multidisciplinary team
  • Willingness and ability to travel to assigned operational areas/facilities.
  • Ability to be flexible with programmatic needs and changes
  • Capable of effective clear direct communication with others (oral and written)
  • Proven management abilities, including meeting deadlines, ensuring compliance with agency policy and procedures, and overseeing complete and timely maintenance of agency records, in accordance with contractual requirements.

To Apply

Interested candidates should submit resume and cover letter to the Human Resources Department, attention: Germain Tillery at: