Care Coordinator Responsibilities:

• Enrollment and Consent:
• Obtain required Care Management enrollment consent from the individual or legal guardian.

Needs Assessment:

• Complete initial and ongoing needs assessments (Child and Adolescent Needs and Strengths; CANS) to determine the individual’s most appropriate level of care management.

Individualized Plan of Care (IPC):

• Responsible for the overall management of the patient’s IPC.
• Coordinate the enrollee’s provision of services per their acuity level.
• Support adherence to treatment recommendations.
• Monitor and evaluate a patient’s needs, including:
• Prevention
• Wellness
• Medical and mental health care
• Care transitions
• Social and community services

Client Contact and Visits:

• Meet client contact requirements:
• Caseloads may be “blended with High, Medium, and Low.”
• Care Coordinators serving children must have face-to-face visits on a consistent schedule based on acuity level (high, medium, or low).

Documentation:

• Meet Care Management documentation requirements timely and accurately using designated Care Management Portals (MAPP, EHR, and HSC).

Advocacy and Support:

• Advocate for clients within the agency and with external service providers.
• Promote wellness and prevention by linking enrollees with resources and services based on individual needs and preferences.
• Educate the child/caregiver on chronic condition care, immunizations, screenings, and other preventive interventions.
• Assist clients in obtaining and maintaining public benefits necessary for health care services, including:
• Medicaid
• Cash assistance eligibility
• Social Security
• SNAP
• Housing
• Legal services
• Employment and training supports

Communication:

• Effectively communicate and share information with the individual, their families, and other caregivers, considering language, literacy, and cultural preferences.
• Care Planning and Coordination:
• Conduct care planning meetings/conferences and serve as an interdisciplinary team member to provide/coordinate comprehensive and holistic care.
• Identify available community-based resources and manage appropriate referrals, access, engagement, follow-up, and coordination of services.
• Hospital and ER Admissions:
• For hospital admissions, engage in the discharge planning process to ensure recommended post-discharge services are in place.
• For ER admissions, meet with members in the Emergency Room as per Health Home mandates.

Staff Development:

• Attend and participate in ongoing staff development training to enhance skills needed for the Care Coordinator position.
• Additional Responsibilities:
• Ensure periodic evaluations and follow-up treatments for dental, vision, and hearing care per Medicaid guidelines.
• Perform other duties as assigned.

Job Type: Full-time

Pay: $24.00 per hour

Expected hours: 40 per week

Benefits:

• Dental insurance
• Disability insurance
• Health insurance
• Life insurance
• Opportunities for advancement
• Paid sick time
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Work setting:

• In-person
• Office

Ability to Commute:

• Fresh Meadows, NY 11365 (Required)

Work Location: In person