Care Coordinator Community

Good Shepherd Services•New York City, NY

1d•Hybrid

About The Position

We are seeking a dedicated and compassionate Bilingual (Spanish-speaking) Care Coordinator to support youth enrolled in our Health Home program. The Care Coordinator will play a key role in guiding participants and their legal guardians through the health care system by addressing access barriers, fostering relationships with service providers, and monitoring interventions and outcomes to ensure high-quality care coordination.

Requirements

Bachelor of Arts or Science degree with two years' experience required
Bilingual Spanish/English speaking candidates are highly encouraged to apply
Must have previous experience as a Case Planner, Care Coordinator, Case Manager, and/or Case Worker in a social service setting
Relevant expertise and experience in serving children and families in child welfare, developmental disabilities, mental health, healthcare, and/or other systems, as well as those receiving preventive services.
Experience providing service coordination and information, linkages, and referrals for community-based services.

Nice To Haves

Experience with Child Welfare; ACS; and Foster Care is helpful
Care Coordinators serving high acuity enrollees will be required to have demonstrated knowledge and understanding of the needs of such children and their families as evidenced by additional years of experience, education, or training.
Care Coordinators assigned to children who have medical fragility must have extensive experience in coordinating their care

Responsibilities

Secure all required Care Management enrollment consents from the individual or their legal guardian.
Conducts initial and ongoing comprehensive needs assessments (Child and Adolescent Needs and Strengths; CANS) to determine the individual’s appropriate level of care management.
Oversee the development, implementation, and ongoing management of the Individualized Plan of Care (IPC), ensuring that: Services are coordinated according to the enrollee’s acuity level. Treatment recommendations are supported and reinforced. The individual’s needs are continuously monitored and evaluated across prevention, wellness, medical, behavioral health, care transitions, and social/community service domains.
Meets all client contact requirements, including: For child-serving Care Managers, completing required face-to-face visits in accordance with the individual’s assigned acuity level (high, medium, or low).
Completes all Care Management documentation accurately and within required timeframes, utilizing the designated Care Management Portal (Medicaid Analytics Performance Portal; MAPP) and Electronic Health Records (EHRs) as appropriate.
Serves as an advocate for clients within the agency and among external service providers.
Promotes wellness and prevention by connecting enrollees to appropriate resources and services based on their identified needs and preferences.
Provides education to children and caregivers regarding chronic condition management, immunizations, screenings, and other preventive health interventions.
Assists clients in obtaining and maintaining public benefits necessary for accessing health care and supportive services, including Medicaid, cash assistance, Social Security, SNAP, housing supports, legal services, and employment or training programs.
Communicates effectively with individuals, families, and caregivers, ensuring sensitivity to language, literacy, and cultural preferences.
Facilitates care planning meetings and participates as a member of the interdisciplinary team to ensure comprehensive, coordinated, and holistic care.
Identifies community-based resources and manages referrals, access, engagement, follow-up, and coordination of services.
Actively participates in hospital discharge planning to ensure that all recommended post-discharge services are arranged prior to the individual’s release.
Attends and participates in ongoing staff development and training to maintain and enhance skills required for effective Care Management practice.
Ensures that children receive periodic evaluations and follow-up treatment for dental, vision, and hearing care in accordance with Medicaid EPSDT guidelines.
Performs all other duties as assigned.