Care Coordinator/ Wraparound Coach

San Felipe Pueblo; New Mexico; On-site; USD 28,000 - 40,000; Full time

Job summary

San Felipe Pueblo seeks a Care Coordinator/Wraparound Coach to coordinate individualized, family-centered services for children, youth, young adults, and families enrolled in CMHI. The role uses Wraparound and Systems of Care, serving as the primary contact for families, convening care meetings, and developing plans of care that are culturally responsive and trauma-informed.

Responsibilities include coordinating services across behavioral health, education, and child welfare, engaging families

Qualifications

• Associate’s degree required in Social Work, Psychology, Counseling, Human Services, Education, Public Health, or related field.
• Minimum of three years of experience working with children, youth, and families in behavioral health, social services, child welfare, education, or related systems.
• Experience facilitating team meetings and collaborating across multiple systems.
• Knowledge of Wraparound principles.
• Bilingual proficiency in Keres and English preferred.
• Proficiency with electronic health records and Microsoft Office applications.

Responsibilities

• Implement the Wraparound process with fidelity to evidence-informed and best-practice standards.
• Conduct comprehensive strengths, needs, and culture discovery activities with youth and families.
• Develop individualized, strengths-based plans of care that reflect family and youth priorities.
• Coordinate services and supports across behavioral health, primary healthcare, education, child welfare, juvenile justice, developmental disability, housing, and community systems.
• Ensure families are active participants in all planning and decision-making activities.
• Monitor implementation of service plans and modify strategies as needed to achieve desired outcomes.
• Organize and facilitate coordinate care team meetings.
• Engage family members, youth, natural supports, providers, and community partners in collaborative planning.
• Ensure meetings focus on family strengths, outcomes, and shared accountability.
• Document meeting outcomes and distribute plans to appropriate team members.
• Support conflict resolution and consensus‑building among team participants.
• Build trusting relationships with youth and families.
• Empower families to advocate for their needs and preferences.
• Assist youth in identifying personal goals and developing self‑advocacy skills.
• Ensure services and supports align with family culture, values, and preferences.
• Promote family leadership and engagement in System of Care activities.
• Collaborate with families and service providers to develop individualized crisis prevention and safety plans.
• Monitor identified risk factors and emerging needs.
• Support timely access to crisis services and community resources when necessary.
• Facilitate communication among team members during periods of increased need or crisis.
• Identify and connect families to formal and informal community supports.
• Maintain knowledge of local behavioral health, educational, social service, housing, employment, recreational, and healthcare resources.
• Develop partnerships with community agencies and organizations to increase available support options.
• Promote the use of natural supports to strengthen long‑term sustainability.
• Maintain accurate and timely documentation in accordance with agency policies and grant requirements.
• Complete assessments, service plans, progress notes, and discharge summaries.
• Track service utilization, referrals, outcomes, and participant engagement.
• Participate in grant‑related data collection, quality improvement, and evaluation activities.
• Ensure confidentiality compliance.

Skills

Engagement

Facilitation

Coordination

Team leadership

Communication skills

Organization

Time management

EHR/MS Office

Education

Associate’s degree in Social Work, Psychology, Counseling, Human Services, Education, Public Health, or a related field

Tools

Electronic Health Records

Microsoft Office

Job description

Responsible for coordinating individualized, family-centered services and supports for children, youth, young adults, and families enrolled in the SAMHSA-funded Children’s Mental Health Initiative (CMHI).

Department:

Pay Grade:

Up to $25.00/hr.

FLSA:

Non-Exempt

Job Description:

The Care Coordinator/Wraparound Coach is responsible for coordinating individualized, family-centered services and supports for children, youth, young adults, and families enrolled in the SAMHSA-funded Children’s Mental Health Initiative (CMHI). Using the principles of Wraparound and Systems of Care, this position that serves as the primary point of contact for enrolled families, convenes coordinated care meetings, develops and monitors individualized plans of care, coordinates cross-system services, and ensures that services are family-driven, youth-guided, culturally responsive, and trauma-informed.

Duties and Responsibilities:

Care Coordination and Wraparound Facilitation

• Implement the Wraparound process with fidelity to evidence-informed and best-practice standards.
• Conduct comprehensive strengths, needs, and culture discovery activities with youth and families.
• Develop individualized, strengths-based plans of care that reflect family and youth priorities.
• Coordinate services and supports across behavioral health, primary healthcare, education, child welfare, juvenile justice, developmental disability, housing, and community systems.
• Ensure families are active participants in all planning and decision-making activities.
• Monitor implementation of service plans and modify strategies as needed to achieve desired outcomes.

Coordinated Care Facilitation

• Organize and facilitate coordinate care team meetings.
• Engage family members, youth, natural supports, providers, and community partners in collaborative planning.
• Ensure meetings focus on family strengths, outcomes, and shared accountability.
• Document meeting outcomes and distribute plans to appropriate team members.
• Support conflict resolution and consensus‑building among team participants.

Family and Youth Support

• Build trusting relationships with youth and families.
• Empower families to advocate for their needs and preferences.
• Assist youth in identifying personal goals and developing self‑advocacy skills.
• Ensure services and supports align with family culture, values, and preferences.
• Promote family leadership and engagement in System of Care activities.

Crisis Prevention and Planning

• Collaborate with families and service providers to develop individualized crisis prevention and safety plans.
• Monitor identified risk factors and emerging needs.
• Support timely access to crisis services and community resources when necessary.
• Facilitate communication among team members during periods of increased need or crisis.

Community Resource Development

• Identify and connect families to formal and informal community supports.
• Maintain knowledge of local behavioral health, educational, social service, housing, employment, recreational, and healthcare resources.
• Develop partnerships with community agencies and organizations to increase available support options.
• Promote the use of natural supports to strengthen long‑term sustainability.

Documentation and Data Reporting

• Maintain accurate and timely documentation in accordance with agency policies and grant requirements.
• Complete assessments, service plans, progress notes, and discharge summaries.
• Track service utilization, referrals, outcomes, and participant engagement.
• Participate in grant‑related data collection, quality improvement, and evaluation activities.
• Ensure compliance with confidentiality regulations and documentation standards.

Team Collaboration and Quality Improvement

• Participate in multidisciplinary staffing meetings and case consultations.
• Collaborate with peer support workers, family coordinators, navigators, clinicians, schools, and community providers.
• Participate in Wraparound fidelity monitoring and continuous quality improvement efforts.
• Contribute to program development and systems‑change initiatives.

Training and Professional Development

• Attend required Wraparound, System of Care, trauma‑informed care, and cultural responsiveness trainings.
• Maintain knowledge of evidence‑based and best‑practice care coordination approaches.
• Participate in ongoing coaching, supervision, and case reviews.

Additional Responsibilities:

This position description in no way states or implies that these are the only duties performed by this employee. He or she will be required to follow any other instructions or to perform any other duties requested by his or her supervisor.

Qualifications, Education and/or Experience:

EDUCATION:

• Associate’s degree in Social Work, Psychology, Counseling, Human Services, Education, Public Health, or a related field required.

EXPERIENCE:

• Minimum of three years of experience working with children, youth, and families in behavioral health, social services, child welfare, education, juvenile justice, healthcare, or related systems.
• Experience providing care coordination, case management, service planning, or family-centered services.
• Experience facilitating team meetings and collaborating across multiple systems.

ADDITIONAL QUALIFICATIONS:

KNOWLEDGE, SKILLS AND ABILITIES:

• Knowledge of Wraparound principles.
• Understanding of children’s behavioral health needs and family-centered practices.
• Strong skills in engagement, facilitation, coordination, and problem solving.
• Ability to effectively organize and lead multidisciplinary team meetings.
• Excellent written, verbal, and interpersonal communication skills.
• Strong organizational and time‑management abilities.
• Ability to manage complex cases and multiple priorities simultaneously.
• Proficiency with electronic health records and Microsoft Office applications.

PREFERRED QUALIFICATIONS:

• Experience utilizing High‑Fidelity Wraparound practices.
• Knowledge of trauma‑informed care, motivational interviewing, and positive youth development approaches.
• Bilingual proficiency in Keres and English preferred.
• Experience serving diverse, underserved, rural, or historically marginalized populations.

PHYSICAL DEMANDS: The work requires driving and involves standing, bending, and walking within the community, schools, clinics, and homes and driving a car in all types of road conditions. Lifting and carrying is necessary to set up equipment for special events and teaching programs.