Care Coordinator

Position Summary

The Care Management Program assists families in ensuring eligible children receive the medical and behavioral health services needed to promote optimal health through service coordination, resource connection, and family support. Reporting to the Care Coordinator Supervisor, the Care Coordinator (CC) is responsible for coordinating services for an assigned caseload by helping program enrollees and caregivers navigate the healthcare system, access community resources, collaborate with service providers, and track interventions and outcomes.

The Care Coordinator provides comprehensive care management services, including assessment, care planning, referrals, outreach, and coordination across healthcare, behavioral health, and community-based systems. This role supports children and families through service integration while ensuring documentation, privacy, and program requirements are maintained in alignment with Children’s Aid policies and applicable regulations.

Essential Duties and Responsibilities

Care Coordination & Client Support

Understand and promote Children’s Aid’s Mission, Vision, and Core Values to ensure alignment with organizational policies and procedures.
Obtain consent and enroll eligible clients in the Collaborative for Children & Families (CCF – the health home).Manage an assigned caseload of up to 35 cases based on client acuity.
Provide the six core care management functions for assigned clients:
Comprehensive Care Management
Care Coordination and Health Promotion
Comprehensive Transitional Care
Individual and Family Support
Referral to Community and Social Support Services
Use of Health Information Technology to support service coordination.
Complete CANS-NY assessments for all enrolled clients initially and, at minimum, every six months, along with comprehensive assessments.
Assess client needs and refer for Home and Community-Based Services (HCBS) as needed.
Collaborate with families and service providers to develop and implement Individualized Plans of Care.
Create crisis and emergency plans for assigned clients.
Provide outreach to potential clients as needed.
Support families in accessing healthcare, behavioral health, and community-based resources by developing and maintaining relationships with service providers and community organizations.
Maintain resource logs for community support and health services.

Documentation & Program Compliance

Document all client activities, including progress notes, in GSI and other required systems accurately and within established timelines.
Maintain accurate records and required documentation to support client care, program reporting, and compliance requirements.
Maintain compliance with privacy laws, including HIPAA, and Children’s Aid policies and procedures.
Provide information and support to Children’s Aid staff and serve as a liaison between Children’s Aid programs as needed.
Complete required billing documentation and program-related forms in a timely manner.

Community-Based Services & Engagement

Conduct fieldwork and home visits as needed, including potential evening and weekend visits.
Utilize public transportation and community-based resources to support client engagement and service coordination.
Build effective working relationships with children, families, providers, and community partners from diverse cultural, social, and economic backgrounds.
Communicate client progress, challenges, and service coordination needs with appropriate staff and stakeholders.

Team Collaboration & Professional Development

Work collaboratively as part of the Care Management Team to support program goals, including established enrollment targets.
Participate in program, division, and agency-wide activities, including meetings, events, and trainings.
Manage competing priorities while maintaining timely follow-up, accurate documentation, and quality service delivery.
Perform other related duties as assigned.

Minimum Qualifications

Bachelor’s degree required.
Two years of related experience required.
Experience serving children and families with chronic medical conditions, developmental disabilities, mental/behavioral health diagnoses, or involvement in the child welfare system.
Ability to communicate effectively, both verbally and in writing, with children, families, providers, and internal partners.
Ability to organize and manage multiple priorities while meeting established deadlines.
Ability to work independently and collaboratively as part of a multidisciplinary team.
Ability to conduct community-based visits, including home visits, and travel throughout assigned service areas.
Ability to work flexible hours, including occasional evenings and weekends as needed.