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Care Coordinator

Supervisor:  Director of Care Coordination Services

Program Overview: New York State's Medicaid Health Home initiative offers care management for beneficiaries with intensive, high-cost service needs. The health home model provides the basis for unified systems of care to coordinate and integrate physical and behavioral health care, chemical dependence treatment, and social services provided to health home members. The target population is: children/youth ages 0 - 21 who have: two or more chronic conditions or one single qualifying condition of Serious Emotional Disturbance (SED) or HIV/ AIDS or Trauma/at risk for another condition.


Health Home Care Coordinators must provide Six Core Services of Health Home Care Management:

1. Comprehensive Care Management

2. Care Coordination and Health Promotion

3. Comprehensive Transitional Care

4. Patient and Family Support

5. Referral to Community and Social Support Services

6. Use of Health Information Technology (HIT) to Link Services

Services are offered based on three acuity tiers: high, medium and low. Care Coordinator will

  • Provide home and community based services to a mixed caseload of high, medium and low acuity cases by conducting a minimum of two visits a month to high & medium acuity cases, with additional modes of contact as deemed clinically appropriate based on client need, and at least one mode of contact a month is required for low acuity cases and as needed.
  • Conduct on-going outreach, assess client, develop care plan and facilitate service delivery.
  • Collaborate with service providers.
  •  Maintain complete care management records
  • Provide crisis intervention, prevention and resolution as required.
  • Provide On-call rotation duties, and coverage as needed.
  • On-going training and professional supervision provided, with opportunity for advancement.
  • Other duties, as assigned by the Program Director.


  • BA in related field and at least two years' experience working with children, preferably in a mental health program. 
  • Knowledgeable of experience with a diverse and multi-cultural population
  • Bilingual in Chinese or Spanish a plus.
  • Demonstrate ability to engage hard-to-reach populations. 
  • Excellent communication and writing skills
  • Ability to work independently and as an effective team player
  • Must be knowledgeable of resources and services in Brooklyn, for children and families.

 Hours: Full-Time (35 hours)

Salary: High 30s to mid 40s plus generous benefits


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