TBI/NHTD SERVICE COORDINATOR

About the Role

Catholic Charities Family and Community Services (CCFCS) has been serving the community for over 100 years, walking with people at their most vulnerable as they journey toward independence. The organization proudly serves and employs people from all backgrounds and experiences. This position offers the chance to make a meaningful impact on the lives of individuals with disabilities and seniors through service coordination within the Traumatic Brain Injury (TBI) Waiver and Nursing Home Transition and Diversion (NHTD) Waiver programs in Monroe, Finger Lakes, or Southern Tier regional counties.

Responsibilities

• Serve as a contact for referrals, gather required documentation, and arrange necessary screenings for intake.
• Provide participant‑guided service coordination to an assigned caseload, maintaining accurate and verifiable documentation of all services rendered.
• Develop and complete comprehensive service plans, PPOs, and other required documentation using a person‑centered approach, as set by the DOH and Regional Resource Development Center.
• Demonstrate, promote, and practice cultural competency toward participants through respect and understanding.
• Recognize and embrace diversity, supporting and encouraging the strengths of each individual served.
• Conduct a minimum of one face‑to‑face meeting for each participant each month (with quarterly home visits) to address service plan goals and monitor provider plan effectiveness.
• Maintain accessibility for clients during the workday using a team approach.
• Assist participants in acquiring and maintaining public benefits such as Medicaid, SNAP, and Social Security.
• Provide linkage, referrals, and coordination of resources for medical care, mental health, social, recreational, and housing/basic needs.
• Stay current in the field and implement best‑practice service models within the program.
• Make independent decisions regarding immediate risk factors, provide crisis intervention, and follow‑up as needed.
• Demonstrate flexibility to be available to clients in their homes/communities, including working outside normal business hours as needed.
• Provide on‑call availability via cell phone to the TBI and/or NHTD program as needed.
• Serve as a participant advocate.
• Ensure annual assessment of need for nursing home facility level of care.
• Facilitate development of a Care Team to carry out individualized, strength‑based Service and Detailed Plans through regular team meetings and plan reviews.
• Participate in staff meetings and other Care Coordination department activities.
• Ensure compliance with all applicable local, state, and federal regulations and agency policies.
• Participate in all mandatory ongoing training and professional development offered.
• Represent Catholic Charities Family and Community Services on appropriate boards and committees as assigned.
• Comply with all agency policies and procedures and attend relevant agency meetings and trainings.
• Pursue development of professional competencies through reading, supervision, in‑service training, and attendance at conferences and workshops.
• Support the agency’s Mission, Vision, Values, and Strategic Plan, including core competency initiatives such as collaboration, community focus, innovation, entrepreneurship, cultural competence, and diversity.
• Perform other duties as assigned.

Qualifications

• Bachelor’s degree plus one (1) year of experience providing case management/service coordination, information, linkages, and referrals for individuals with disabilities and/or seniors.
• Or Associate’s degree plus two (2) years of comparable experience.
• Paid employment, documented volunteer work, internships, or other unpaid experience providing case management/service coordination may be used to fulfill the experience requirement.

Requirements

• Physical demands include frequent sitting, talking, hearing, standing, walking, and using hands to type; occasional light lifting.
• Vision requirements: close vision, distance vision, and ability to adjust focus.
• Work environment is usually quiet.
• Adherence to all applicable federal and state laws and regulations, including confidentiality, privacy, program, billing, and documentation standards.
• Compliance with CCFCS’s corporate compliance & ethics program.
• Successful completion of a background check is required for employment.

Benefits

• Competitive salary and 403(b) retirement plan.
• Generous time‑off package and work‑life balance.
• Comprehensive benefits package.
• Supportive and collaborative environment.
• Opportunities for growth and development.
• Intrinsic reward of truly making a difference in people’s lives.

Pay

$25.00 per hour.

Schedule

Full‑Time, Monday – Friday, 40 hours per week.