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Tbi​/Nhtd Service Coordinator

Job in City of Rochester, Rochester, Monroe County, New York, 14602, USA
Listing for: Fcscharities
Full Time position
Listed on 2026-02-01
Job specializations:
  • Healthcare
    Community Health, Mental Health
  • Social Work
    Community Health, Mental Health
Salary/Wage Range or Industry Benchmark: 25 USD Hourly USD 25.00 HOUR
Job Description & How to Apply Below
Position: TBI/NHTD SERVICE COORDINATOR
Location: City of Rochester

Description

We are Hiring!

Job Posting: TBI/NHTD Service Coordinator

Location: Rochester, NY

Department: Care Coordination

Employment Type: Full-Time

Schedule: M-F, 40 hours

Salary: $25.00/hr.

As a regional agency of Catholic Charities of the Diocese of Rochester, Catholic Charities Family and Community Services (CCFCS) has been serving our community for over 100 years. We walk with people when they are at their most vulnerable as they journey toward independence to reach their full human potential, advocate for those in need throughout all stages of life; and work in partnership with faith communities of all denominations and those who are committed to addressing local needs.

If you’re looking for an opportunity to express and explore your passion for helping others, then join a team that truly makes a difference DAILY, in people's lives. Don't miss out on being a part of something special!

General Description

Provide service coordination to individuals within the Traumatic Brain Injury (TBI) Waiver and Nursing Home Transition and Diversion (NHTD) Waiver programs living in Monroe, Finger Lakes or Southern Tier Regional Counties. Ensures completion of required duties for each shift. Effectively supports ongoing and collaborative communication amongst all program staff and is responsible for ensuring a trauma informed care environment.

Essential Duties and Responsibilities >
  • When needed, serve as contact for referrals, gathering required documentation, and arrange for necessary screenings to proceed with intake in applicable program.
  • Provide participant-guided service coordination to caseload assigned, maintaining accurate and verifiable documentation of all services rendered.
  • Using a person-centered approach, develop and complete comprehensive service plans, PPOs, and all other required documentation as set by DOH and Regional Resource Development Center.
  • Demonstrate, promote and practice cultural competency towards participants through respect and understanding.
  • Recognize and embrace diversity through supporting and encouraging the strengths of each individual served.
  • Provide a minimum of 1 face to face contact meeting for each participant assigned monthly (meeting must in the participants home on a quarterly basis), to ensure all service plan goals are addressed to the satisfaction of the participants served and to monitor overall provider plans effectiveness.
  • Utilizing a team approach, maintain accessibility for clients during the workday.
  • Assist participants in the acquisition and maintenance of public benefits e.g., Medicaid, SNAP, Social Security, etc.
  • Provide linkage/referrals and coordination of resources/support for medical care, mental health, social, recreational and housing/basic needs, etc.
  • Remain current in the field, support and implement best practice service models within the program.
  • Make independent decisions and recommendations regarding immediate risk factors presented and provide crisis intervention and follow-up as needed.
  • Demonstrate flexibility to be available to clients in their homes/communities including working outside of 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 the assessment of need for a nursing home facility level of care on an annual basis.
  • Facilitate the development of a Care Team to carry out individualized and 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.
  • Complies with all agency policies and procedures.
  • Participates in relevant Agency meetings and/or trainings
  • Actively pursues development of professional competencies related to job role performance through reading, supervision, in-service training and attendance at conferences and workshops.
  • Awareness and active…
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