Care Coordinator, Community

Job Description

Job Description

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.

Good Shepherd Services is a leading youth development, education, and family services agency, operating more than 80 programs and serving over 30,000 children, youth, and families annually. Our mission is to empower vulnerable young people in New York City to take ownership of their futures. Recognized by Crain’s New York as one of the top 100 places to work in NYC, Good Shepherd Services offers an exceptional work environment, a collaborative and mission-driven team, and a comprehensive benefits package. We invite you to join our organization and contribute to meaningful, lasting change in the lives of the youth and families we serve.

Reports to: CARE MANAGER SUPERVISOR, HEALTH SERVICES

Location: 685 E. 187th Street, Bronx, NY 10458

Hours: 35 hours, Non-Exempt (Staff are expected to be on-site as requested. Hybrid schedules may be provided based on program needs and leadership discretion.)

Salary Range $44K - $49K/Year

Major Duties Care Coordinator:

• 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.

Qualifications of Care Coordinator

Education and/or credential requirements are determined by children’s 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.