Care Coordinator - Care Coordination

Colonial Group; City of Geneva (NY); On-site; USD 52,000 - 75,000; Full time

Job summary

Colonial Group in New York seeks a Care Coordinator to oversee holistic care coordination across health, behavioral health, and community supports. You will develop person-centered Life Plans with the individual and support team, ensuring informed decision-making and timely documentation.

Travel to individuals’ homes and other settings is common, and collaboration with providers is essential. A NY driver’s license and relevant care coordination experience are required to excel in this role.

Qualifications

• Bachelor’s degree with 2+ years relevant experience, OR RN with 2 years, OR Master’s with 1 year.
• New York State driver’s license required.
• Experience with health home and person centered planning regulations is preferred.

Responsibilities

• Coordinate all aspects of an individual’s care using a holistic, person-centered approach.
• Develop and maintain a comprehensive Life Plan with the individual and support circle.
• Review Life Plan with the interdisciplinary team at least annually or after life-changing events.

Skills

Communication skills

Time management

Interpersonal skills

Motivational interviewing

SMART goals

Cultural competence

Organizational skills

Education

Bachelor’s degree with 2 years relevant experience

Licensed Registered Nurse with 2 years relevant experience

Master’s degree with 1 year relevant experience

Job description

Care Coordinator

JOB SUMMARY

The care coordinator has an overall responsibility and accountability for coordinating all aspects of the individual’s care, including but not limited to health and behavioral healthcare, community supports, and other services required to meet the needs of the individual. For individuals who are enrolled in the health home, the care coordinator will take a holistic approach to care by utilizing the core standards of service. These include:

• 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 (HIT) to Link Services

ESSENTIAL FUNCTIONS

• Completes required assessments using person centered planning techniques, as well as gathers and incorporates all other relevant assessments.
• Develops a comprehensive, person-centered Life Plan with the individual and their circle of support, as well as their entire service provider team.
• Supports the individual in the planning process to ensure that the individual directs the process to the maximum extent possible and can make informed decisions and choices.
• Reviews the Life Plan with the individual’s entire interdisciplinary team no less than annually, and every time there is a life changing event. This review must occur during a face-to-face meeting, no less than annually.
• Accountable for coordinating all aspects of an individual’s care.
• Effectively manage a tiered caseload, while tailoring services to individual needs.
• Completes program enrollment and eligibility document.
• Completes and secures consents and authorizations to share information.
• Develops and maintains appropriate records.
• Completes and reviews paperwork necessary for case files and reports.
• Completes documentation and billing in a timely manner.
• Frequent travel meeting with individuals in their homes, physician/provider offices, and other public places in order to conduct assessments and provide services.
• Accompanies individuals to appointments in accordance with Person Centered Services policy.
• Collaborates with providers and service support team members.
• Initiate incident reports and follow-up to ensure compliance with regulations.
• Monitors individual satisfaction with supports and services.
• Ensures case files are in compliance with regulation and policy.
• Provide quality driven, cost effective, culturally appropriate services.

OTHER DUTIES

• Commits to a respectful, just, and supportive environment for individuals and team members aligning with the company’s commitment to diversity, equity, inclusion and belonging.
• Other duties as necessary or assigned.

KNOWLEDGE, SKILLS & ABILITIES

• Knowledge of developmental disabilities, chronic disease, and social determinants of health.
• Strong knowledge of OPWDD funded services and supports.
• Experience with motivational interviewing.
• Experience writing SMART goals.
• Knowledge of person-centered planning regulations.
• Ability to build relationships and effectively communicate.
• Encourages community integration.
• Demonstrates cultural competence.
• Demonstrates ethical and professional responsibilities and boundaries.
• Demonstrates capacity to use Health Information Technology to link services and facilitate communication.
• Knowledge of confidentiality regulations.
• Organizational and time management skills
• Ability to prioritize.
• Proactively approaches professional responsibilities.
• Completes work in a timely manner

EDUCATION & EXPERIENCE

• Bachelor’s degree with 2 years relevant experience OR a Licensed Registered Nurse with 2 years relevant experience OR A Master’s degree with 1-year relevant experience required.
• A valid New York State driver’s license is required. If residing in a bordering state, a valid driver’s license from that state is acceptable for employment in New York.