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Job Description ABOUT JFS For more than 150 years, Jewish Family Services of Western New York has been committed to providing high quality services to all in need in the interest of helping to "repair the world." Our services are guided by the essential connection between mental well-being, physical wellness, and positive self-worth. Our reputation is the result of our exceptional staff. In addition to offering competitive compensation and truly exceptional benefits, we are committed to providing a supportive, inclusive work environment in which all employees are able to contribute their best. OUR VALUES Be a Mensch: We are ethical, kind, and admirable. We assume good intent and act with integrity. We are thoughtful and deliberative in how we support our clients, each other, and the community. “Choose generosity over judgment—every time” Be Purpose-Built: We create spaces and programs that respect clients’ individuality and opens access. We strive to meet the individual where they’re at and give them the tools to be successful Be Resolute: We work with tenacity to identify problems, seek out solutions, and get things done. Even small steps forward are acts of resilience. SUMMARY Care Coordinators work in collaboration to ensure that Health Home consumers receive comprehensive care coordination. As part of the Children’s Health Home Team, the Care Coordinator is responsible for managing all aspects of care for child & family Health Home consumers which includes tracking and arranging appointments, working in partnership with treatment providers, offering consumer advocacy and education, and coordinating other aspects of the consumer's community services. RESPONSIBILITIES & DUTIES A representative summary of tasks to be performed is provided below. The employee may be asked to perform job-related tasks other than those specifically stated in this description. The duties and responsibilities of the position are to be carried out in a manner that is consistent with the mission, values, and operating principles of Jewish Family Services. • Coordinate all services for assigned children’s caseload dependent on assessment of needs (High, Medium, or Low)., • Conduct home visits with clients and travels into the community to meet with clients in other community-based settings, including medical provider appointments, hospitals, residential settings, and other community service provider offices., • Administer CANS and utilize HCS (Health Commerce System), (MAPP & UAS) assessment tools and utilize results to link to additional needed services (Level II)., • Regularly obtains and documents consent on the DOH 5201 and DOH 5055 forms as appropriate., • Promote client rights and access to social service, social security, mental health, and other support services., • Conduct comprehensive assessment and develop a patient-centered Plan of Care to address client needs. Assist clients with achieving their goals, in accordance with the Plan of Care., • Complete crisis plan with all client on assigned caseload and review with client and their caregivers at least annually., • Conduct regular case review with client and members of the client’s care team to review the Plan of Care and address barriers that prevent client from meeting their Plan of Care goals., • Complete the monthly Children’s Billing Questionnaire for each client on their assigned caseload by the last business day of each month., • Coordinate care across the system including help in utilizing resources, accessing health related services, and overcoming barriers to clients obtaining needed medical care and social services., • Work directly with clients, family/caregivers, and discharge planners to assist in transition planning., • Assist client and caregivers with coordination of appointments including but not limited to scheduling, rescheduling, providing appointment reminders and arranging transportation., • Work closely with the interdisciplinary care team including primary care providers, MCO, medical specialists, mental health providers, residential services, substance abuse treatment program, etc., • Work collaboratively with schools and other educational providers to ensure client’s needs are met., • Continuously expand knowledge and understanding of community resources, services and programs provided; human relations and the procedures used in dealing with the public as part of a service or program., • Conduct timely follow-up with inpatient facilities and local emergency rooms upon client admission, coordinate with discharge planners, and ensure client linkage to after care with primary care provider and specialists., • Provide culturally appropriate and sensitive care coordination services to our diverse population, including the use of language line and other translation services and advocate for language access with providers., • Accurately document all interactions with clients and all efforts made towards client engagement. Submit all progress notes within 48 hours of the client encounter., • Effectively utilize electronic systems, including Netsmart, HEALTHeLink, PSYCKES, and ePACES., • Maintain on-going communication with program manager about their assigned caseload and seek out supervisory support when needed., • Attend agency and department in-service training and staff meetings as well as any other agency related activities as required. Education and Experience: • Bachelor’s Degree in relevant discipline required; social work or other behavioral related area preferred., • Experience in care coordination/ care management highly preferable., • Familiarity with electronic health record management system a plus., • Familiarity with community linkage resources helpful., • Ability to effectively provide care management services, responding supportively and with persistence to the client families and demonstration of an understanding of the community and available resources., • Willingness to work within the community, complete home visits and directly transport clients., • Ability to occasionally work outside normal work hours to meet client / outreach needs., • Judgment and Decision Making - Considers relative pros and cons of potential actions to choose the most appropriate one., • Time Management – Uses time effectively and efficiently; values time; concentrates efforts on the more important priorities; gets more done efficiently and effectively., • Adaptability & Flexibility - Adapts to changing business needs, conditions, and work responsibilities, • Client Focus - Understands and meets customer needs, whether internal or external, providing a high level of service and cooperation courteousness & sensitivity), • Will work in the office and in the community; able to travel outside the office to various sites to attend meetings and provide support services., • Must have access to a reliable vehicle, possess a valid, clean NYS driver’s license and be sufficiently self-insured with liability insurance in the amount of $100,000/$300,000., • Light physical activities and efforts required working in an office environment., • Visual acuity sufficient to maintain system of files and reports containing computer-generated and handwritten documents., • Auditory acuity sufficient to communicate with staff and others by phone and in person., • Competitive salary of $23.00 to $25.00 per hour, commensurate with experience and qualifications., • Health, Dental, and Vision insurance., • Accrued Paid Time Off (PTO) of 4+ weeks., • 401k retirement plan with agency contribution of 4%., • 13+ observed holidays annually. Jewish Family Services of Western New York is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.