POSITION SUMMARY: The Care Management Program assists families with ensuring eligible children receive the medical and behavioral health care services they need to promote optimal health by linking, accessing and supporting families through service integration. The Care Coordinator (CC) is responsible for the overall provision and coordination of services to assigned caseload. The CC guides program enrollees and their caretakers through the health care system by assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes. RESPONSIBILITIES:Obtain consent & enroll eligible clients in the Collaborative for Children & Families (CCF the health home)Responsible for the care management of a mixed acuity caseload of up to 35 cases, depending on the acuity.Carry out 6 core care management functions for assigned caseload: Comprehensive Care Management, Care Coordination & Health Promotion, Comprehensive Transitional Care, Individual & Family Support, Referral to Community and Social Support Services, use of Health Information Technology to link servicesComplete CANS-NY assessment on all enrolled clients on caseload (initial and, at minimum, every 6 months) along with the completion of a comprehensive assessmentAssess and refer for Home and Community Based Services (HCBS) as neededCollaborate with family and other providers on development and execution of Individualized Plan of CareDocument all activities including progress notes in GSI, in an accurate and timely manner and other systems as neededCreate Crisis/emergency plan for each clientProvide information to Childrens Aid (CA) staff & Liaison between CA programs as neededProvide outreach to potential clients as neededHelp create linkages to community services for future resource for families as well as source of potential referralsHelp maintain a resource log for community supports and health servicesConduct field work & home visits as needed (possibility of evenings or weekends)Must abide by privacy laws including HIPAA, etc.Work as part of the Care Management Team in all areas, focus on meeting established enrollment targetsParticipate in Program, Division and Agency wide activities (meetings, events, etc.)Attend trainings as requiredOther duties as assigned SKILLS AND QUALIFICATIONS:Minimum Bachelors Degree required with 2 years related experienceOrganized self-starterExperience in serving children and families with chronic medical conditions, developmental disabilities, and mental/behavioral health diagnoses, or those involved in the child welfare systemExcellent organizational and time management skillsComfortable conducting field visits and utilizing public transportationStrong verbal and written communication skillsAbility to engage disenfranchised populationAbility to multitaskEmpatheticAbility to work flexible hours; some nights and weekends may be requiredBilingual Spanish/English preferred
