Care Coordinator, Brooklyn

Major Duties

• 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 individuals 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 enrollees acuity level.
• Treatment recommendations are supported and reinforced.
• The individuals needs are continuously monitored and evaluated across prevention, wellness, medical, behavioral health, care transitions, and social/community service domains.
• Maintains all client contact requirements, including:
• Completing required face-to-face visits in accordance with the individuals assigned acuity level (high, medium, or low).
• Completing 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.
• Aids 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.
• Manages referrals, access, engagement, follow-up, and coordination of services.
• Facilitates hospital discharge planning to ensure that all recommended post-discharge services are arranged prior to the individuals 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.

Qualifications

• Education and/or credential requirements are determined by childrens acuity level and requires one or more of the following:
• 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
• Experience with Child Welfare; ACS; and Foster Care is helpful
• The candidate must possess the following Experience:
• 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.
• 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.
• Experience providing service coordination and information, linkages, and referrals for community-based services.