Care Coordinator

Care Coordinator

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.

To help children in poverty to succeed and thrive. We do this by providing comprehensive support to children and their families in targeted high-needs New York City neighborhoods. Children's Aid annually serves children and their families at over forty sites in New York, as well as through three national program models. Children's Aid is concentrating its efforts on creating cradle-through-college pathways in high-need neighborhoods, with a focus on children's health, family stability, education, and social and emotional development.

We put children, youth, and families first: We listen to and incorporate the voices of children, youth, and families in all that we do.

We seek equity and transformation in our communities: We courageously work within and outside systems to create opportunities for children, youth, and families.

We strive for excellence: We hold ourselves to the highest standards and are committed to continuous learning and improvement.

We are powered by collaboration: Our work is stronger when we trust, partner, and respect each other and the communities we serve.

We are driven by compassion: We lead with kindness, care, and empathy and believe in the endless potential of the people we serve and our team.

Essential Duties and Responsibilities

• 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.

It is the policy of Children's Aid to provide equal employment opportunity to all employees and applicants for employment and is dedicated to maintaining a work environment that is free from harassment and discrimination. Children's Aid will not tolerate discrimination, harassment, or retaliation on any basis, including race, creed, color, national origin, ethnicity, alienage or citizenship status, gender/sex (including pregnancy), disability, religion, source of income, sexual orientation, gender identity or expression, age, familial status, caregiver status, military status, marital or partnership status, status as a victim of domestic violence, sexual violence or stalking, predisposing genetic characteristics, arrest or conviction record, credit history, unemployment status or any other characteristic protected by federal, state or local law. Children's Aid is committed to complying with applicable state and local laws governing non-discrimination in employment. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Children's Aid will conduct a prompt and thorough investigation of all allegations of discrimination, harassment, retaliation, or any violation of the Equal Employment Opportunity Policy in a confidential manner and will take appropriate corrective action, if and where warranted. Children's Aid prohibits retaliation against employees who provide information about, complain about, or assist in the investigation of any complaint of discrimination or violation of the Equal Employment Opportunity Policy.

The incumbent is expected to work a schedule, whether in-person or hybrid, as determined by the department's needs to facilitate effective collaboration with the team. This flexibility is essential for maintaining seamless communication, fostering teamwork, and ensuring the smooth operation of the department's processes. The position's requirements are subject to periodic review and adjustment based on organizational needs and changes in work dynamics.

Travel Required

Yes. This position requires travel throughout the Bronx and Manhattan.

Qualifications

Skills

Preferred

Bilingual (English + Spanish)

Advanced

Behaviors

Preferred

Detail Oriented:

Capable of carrying out a given task with all details necessary to get the task done well

Motivations

Preferred

Ability to Make an Impact:

Inspired to perform well by the ability to contribute to the success of a project or the organization

Education

Required

Bachelors or better.

Experience

Required

2-3 years:

Experience serving populations with chronic medical conditions