Care Coordinator, Foster Care, Bronx

Good Shepherd Services•Bronx, NY

About The Position

Good Shepherd Services is seeking a dynamic and compassionate Care Coordinator to guide program enrollees and their legal guardians through the health care system. The role supports access to care, develops relationships with service providers, and tracks interventions and outcomes. Care Coordinators manage each patient’s Individualized Plan of Care, coordinate services according to acuity, support treatment adherence, and monitor health and social needs. They advocate for clients, connect them with community resources and public benefits, and coordinate with families, caregivers, providers, and interdisciplinary teams. The position serves children in foster care and related programs in the Bronx, with contact schedules and responsibilities based on each enrollee’s acuity level. Good Shepherd Services is a youth development, education, and family service agency with more than 80 programs serving over 30,000 children, youth, and families each year. The organization describes its work as helping vulnerable youth in New York City take ownership of their future and emphasizes a collaborative work environment and commitment to its mission.

Requirements

One or more of the following education or credential pathways, as determined by children’s acuity level: a bachelor’s degree in arts or science with two years of experience; Registered Nurse or Licensed Practical Nurse with two years of experience; or a master’s degree in a related field.
Relevant expertise and experience serving children and families in child welfare, developmental disabilities, mental health, healthcare, other systems, and/or preventive services.
Experience providing service coordination and information, linkages, and referrals for community-based services.
For care coordinators serving high-acuity enrollees, demonstrated understanding of the needs of these children and their families, evidenced by additional years of experience, education, or training.
For care coordinators assigned to medically fragile children, extensive experience coordinating their care.
Commitment to Good Shepherd Services’ mission, vision, and values, including participation in quality-improvement activities and willingness and ability to work in a culturally diverse environment.

Nice To Haves

Bilingual ability.
A license for candidates with a master’s degree in a related field is preferred.

Responsibilities

Obtain required Care Management enrollment consents from individuals or their legal guardians.
Complete initial and ongoing Child and Adolescent Needs and Strengths (CANS) assessments to determine the appropriate level of care management.
Manage each patient’s Individualized Plan of Care.
Coordinate enrollee services according to acuity level and support adherence to treatment recommendations.
Monitor patients’ prevention, wellness, medical, mental health, care-transition, and social and community service needs, as appropriate.
Meet client-contact requirements, including consistent face-to-face visits for children according to acuity-level mandates.
Complete Care Management documentation accurately and on time using the designated Care Management Portal (MAPP) and electronic health records as needed.
Advocate for clients within the agency and with external service providers.
Promote wellness and prevention by connecting enrollees with resources and services that match their needs and preferences.
Educate children and caregivers about chronic-condition care, immunization, screening, and other preventive interventions.
Help clients obtain and maintain public benefits and supports needed to access health care, including Medicaid, cash assistance, Social Security, SNAP, housing, legal services, and employment and training supports.
Communicate and share information effectively with individuals, families, and caregivers while considering language, literacy, and cultural preferences.
Conduct care-planning meetings and conferences and participate as an interdisciplinary team member to coordinate comprehensive care.
Identify community-based resources and manage referrals, access, engagement, follow-up, and service coordination.
Engage in hospital discharge planning and ensure recommended post-discharge services are in place before discharge.
Attend ongoing staff-development training to build skills for the Care Manager position.
Ensure children receive periodic evaluations and follow-up treatment for dental, vision, and hearing care in accordance with Medicaid EPSDT guidelines.
Perform other duties as needed.
Participate in quality-improvement activities and work within a culturally diverse environment.