POSITION TITLE: Care Coordinator

PROGRAM: Care Coordination

GENERAL STATEMENT OF RESPONSIBILITIES:

Care Coordinators provide service brokerage, linkages, coordination, follow-up and advocacy. Care Coordinators utilize strength-based, family-driven, youth-guided, culturally responsive principles to develop individualized, therapeutic relationships with families. The purpose of Care Coordination is to ensure that multiple services are delivered in a coordinated and therapeutic manner, and that they can move through the system of services in accordance with their changing needs.

Eligible children display serious emotional and behavioral disturbances and require an intensive coordination of multiple services to meet those needs. The age range for these children is from age 0-18. (Level III children; see Practice Standards for Systems of Care/Community Collaboratives)

SUPERVISION: Supervised by: Team Leader of Care Coordination Services
Supervises: No one

EXAMPLES OF RESPONSIBILITIES:

1. Accept referrals as assigned by the Care Coordination Supervisor and manage a “caseload” of approximately 10-12 families.
2. Meet with families at a time and location that is most convenient to them. This may include doing home visits on evenings, weekends and holidays, as needed.
3. Maintain weekly in-person and/or phone contact with families served and
document all contacts.
4. Perform family assessments using “Wraparound” principles and standardized forms (“Uniform Client Record” -“UCR”, etc.). This includes the identification of Family Strengths, Vision, Needs, and Strategies in the development of an Individualized Service Plan.
5. Assist families in setting up and convening Child Specific Team (CST) meetings – at least once per month – to develop, implement, and monitor progress on their Individualized Service Plan.
6. Help families to manage crises through the development and implementation of a proactive and reactive safety/crisis plan.
7. Maintain records on all Care Coordination children and families.
8. Maintain confidentiality in management of records and communications regarding families – including obtaining appropriate consents to release information.
9. Attend school-related meetings (e.g. “PPTs”) with families, as needed – providing advocacy and support for the family at those meetings.
10. When appropriate, access “Flex-funds” to help meet family needs identified in the CST process and documented on the family’s service plan (within Flexible Funding Guidelines and available funds).
11. Develop knowledge of existing community resources and educate families on resources that will best meet their needs.
12. Inform families about the local “System of Care Community Collaborative”.
13. Provide families with an explanation of Family Advocacy Services. Refer families for family advocacy [e.g. “FAVOR”], when indicated.
14. Inform families about available Family Support Groups and other “natural supports” available to them in the community.
15. Complete case closure forms (per the UCR) and ensure a smooth transition out of Care Coordination. Obtain satisfaction surveys at the time of case closure.
16. Collect and report data on admissions/discharges.
17. Regularly attend monthly Community Collaborative meetings and present identified service gaps and needs. Seek assistance from the Collaborative in filling those gaps and in identifying formal and natural community supports for families.
18. Work in collaboration with the DCF Social Worker(s) - when DCF is involved - to ensure seamless, collaborative care management.
19. Attend mandatory meetings and/or trainings as designated by Supervisor, DCF, local Systems of Care, etc.
20. Attend weekly local Care Coordination Supervision meetings and monthly regional Coaching/Mentoring sessions. Actively participate in group supervision.
21. Other duties as assigned by the Supervisor.

QUALIFICATIONS:

Education and Experience:
Care Coordinators should possess a college degree (BA, BS or BSW) or (MA, MS, MSW, MFT) in a human service field (e.g., social work, marriage and family therapy, counseling, or psychology, etc.). In exceptional circumstances, persons with a degree in an unrelated field or without a college degree may be considered if they have at least 5 years’ experience in human services. Care Coordinators must have the skills necessary to meet the cultural and linguistic needs of the families to be served by the Systems of Care. Bi-lingual (Spanish-English) may be required.

The successful candidates must have the ability to maintain the utmost confidentiality. Must be capable of both working independently and as part of a team.

Valid drivers license is required. Reliable and personal transportation as well as proof of auto insurance required for this position.