Care Coordinator

Job Definition

The Care Coordinator functions as a member of an interdisciplinary team to provide care coordination to adults diagnosed with a severe mental illness, with multiple medical co‑morbidities and/or co‑occurring substance abuse disorders. The Care Coordinator advocates for and supports the client, engages with community agencies, health care providers and others on the client’s behalf to ensure access to services, to increase wellness self‑management and to reduce emergency room visits and/or hospitalizations.

The Care Coordinator will provide expert support and psychosocial and/or substance abuse interventions, and resources to aid in the consumer’s care while maintaining focus on outcomes and best practices. The Care Coordinator must be available on an as‑needed basis 24 hours a day, 7 days a week.

Bachelor’s Degree or Master’s Degree in one of the following fields preferred:
Social Work, Psychology, Education, Rehabilitation, Occupational Therapy, Counseling, Community Mental Health, Sociology, Speech and Hearing, Physical or Recreational Therapy. Degrees in other related areas may be considered.

• For H.S. Diploma/GED level candidates: four (4) years of related human service and direct service experience required.
• For B.A. level candidates: one (1) year of related human service and direct service experience required.
• Experience in providing direct services to individuals with severe mental health disorders, co‑occurring substance abuse disorders, developmental disorders, and/or physical disabilities, in linking clients to a broad range of services essential to independent community living, and in advocacy for underserved or disenfranchised populations.
• Bilingual preferred.
• Working knowledge of computer software and electronic health record systems.
• Demonstrated competency in written, verbal and computational skills to present and document records in accordance with program standards.
• Experienced in and demonstrated comprehensive understanding and working knowledge of the interdisciplinary planning process and the developmental treatment model.
• Knowledge and sociological understanding of Medicaid, Social Security and other entitlements preferred.
• Excellent interpersonal skills required.
• Knowledge of cultural competence and sensitivity.
• Ability and willingness to regularly travel, in some instances with clients in agency vehicles, to many locations using various modes of reliable and safe transportation. If working in Nassau or Suffolk Counties, a valid Tri‑state driver’s license is required; and you must have a current and valid driver’s license on file with CNGCS Human Resources, be designated, and remain in good standing as a CNGCS authorized driver.

• Conduct initial and ongoing assessments of assigned clients to document strengths, needs, goals and resources.
• Participate in the development, documentation, review and update of client‑centered comprehensive, integrated, interdisciplinary care plans in consultation with Program Supervisor and other team members to ensure focus on desired outcomes.
• Maintain effective communications with clients, primary care physicians, substance abuse and mental healthcare providers, family, collateral resources and other agency staff on behalf of clients.
• Maintain documents, records, statistics, and other related reports in an organized, timely and accurate manner as per policy and procedure.
• Coordinate care planning with other providers of services/resources to ensure goal‑directed, collaborative care, including care transitions.
• Work as part of a Care Coordination team; attend and participate in team meetings to provide input/feedback around psychosocial conditions/comorbidities to review client status, update plans and goals, review outcomes to further program goals.
• Act as a resource/consultant to all team members on psychosocial and/or substance abuse issues and resources.
• Provide telephonic as well as face‑to‑face outreach, engagement and service planning in the field.
• Act as a linkage to community services including medical, behavioral, residential, entitlement and any other needed…