This position is responsible for Care Coordination of services. This is a time limited service that assists children and families with behavioral health conditions who are not effectively engaged with case management or other behavioral health services and supports to achieve their wellness goals.
Care Coordination ensures goals and strategies of the care plan are tied to observable or measurables of success, monitors progress in terms of these indicators and revises the plan accordingly.
ESSENTIAL DUTIES AND RESPONSIBILITIES: to include the following: Other duties may be assigned.
1. Children’s Care Coordination should adhere to the National Care Coordination Standards for
Children and Youth with Special Health Care Needs (CYCHCN). The six domains include
a. Screening, identification and assessment
b. Shared Plans of Care
c. Team-based Communication
d. Child and Family Empowerment and Skill Development
e. Care Coordination Workforce
f. Care Transitions
2. Responsible for being a community resource for children and their families upon receipt of a
referral from schools, service providers, state agencies, families and community partners.
3. Care Coordinator will go to the individual to build trust and rapport upon then Coordinating linkage
of services, supports and cross system collaboration to ensure individuals needs are met in the least
restrictive environment.
a. Improving transitions from acute and restrictive programs (i.e. CSU, inpatient care and
b. DJJ facilities) to less restrictive community-based levels of care that provide outpatient community integration.
b. Increases diversion from residential treatments facilities (SIPP)
c. Reduces entry into the child welfare system of care
4. Actively seeks out and encourages the full participation of the consumers networks of interpersonal
and community relationships while ensuring the care plan reflects activities and interventions that
draw on the sources of natural supports.
5. Completes any required standardized assessments that may be used to determine a level of care.
6. Maintains contact with schools, service providers, state agencies, families and community partners for
shared decision making.
7. Organizes and tracks data in a timely and efficient manner.
8. Identifies deficiencies in current service array and provides feedback to appropriate community
agencies on identified gaps in services.
9. Documents services, meetings and care plans in a timely manner.
10. Attends provider and consumer team meetings as requested.
11. Understands and advocates the use of all state, local, and contracted funding streams.
12. Confers with the Program Director on issues or concerns and documents responses in an appropriate
and timely manner.
13. Maintains a data base of community resources.
14. Participates in outreach and training activities when requested and required.
15. Completes all other duties as assigned.