Overview

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 services
  • Complete CANS-NY assessment on all enrolled clients on caseload (initial and, at minimum, every 6 months) along with the completion of a comprehensive assessment
  • Assess and refer for Home and Community Based Services (HCBS) as needed
  • Collaborate with family and other providers on development and execution of Individualized Plan of Care
  • Document all activities including progress notes in GSI, in an accurate and timely manner – and other systems as needed
  • Create Crisis/emergency plan for each client
  • Provide information to Children’s Aid (CA) staff & Liaison between CA programs as needed
  • Provide outreach to potential clients as needed
  • Help create linkages to community services for future resource for families as well as source of potential referrals
  • Help maintain a resource log for community supports and health services
  • Conduct 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 targets
  • Participate in Program, Division and Agency wide activities (meetings, events, etc.)
  • Attend trainings as required
  • Other duties as assigned 

SKILLS AND QUALIFICATIONS:

  • Minimum Bachelor’s Degree required with 2 years related experience
  • Organized self-starter
  • Experience in serving children and families with chronic medical conditions, developmental disabilities, and mental/behavioral health diagnoses, or those involved in the child welfare system
  • Excellent organizational and time management skills
  • Comfortable conducting field visits and utilizing public transportation
  • Strong verbal and written communication skills
  • Ability to engage disenfranchised population
  • Ability to multitask
  • Empathetic
  • Ability to work flexible hours; some nights and weekends may be required
  • Bilingual Spanish/English preferred
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