Community Care Coordinator

Job Description

Connecticut Children’s Center for Care Coordination (The Center) is dedicated to the integration of care coordination through the delivery of innovative programs, providing technical assistance, disseminating best practices, and building inclusive partnerships to strengthen families and build stronger communities. The Center utilizes a universal, evidence based, research informed, and policy driven approach to enhanced care coordination that not only meets the interrelated medical, developmental, behavioral, and social needs of children, but enhances the care giving capacity of families.

Provide care coordination services to all children (including children and youth with special health care needs and children who are vulnerable and at risk for poor outcomes) by supporting and assisting families with accessing and securing appropriate community services and resources.

Responsibilities

Direct Care Coordination:

• Provide comprehensive care coordination services to children, youth, and their families by linking them to appropriate medical, developmental. Behavioral, educational (etc.), and social services and resources.
• Utilizes the strength based approach, Strengthening Families™, The 5 Protective Factors Framework, to partnering with families.
• In collaboration with families and in consultation with primary care providers and specialty providers, develop and implement a comprehensive, shared plan of care that addresses specific needs and goals
• As an integral member of the care coordination team, collaborate with inpatient, outpatient, and behavioral health team members to ensure transitions in care across the continuum that will mitigate the potential for gaps in care, redundancy, duplication, and poor health and wellbeing outcomes.
• Participate and advocate for families during medical appointments, school meetings, case conferences, etc. as appropriate
• Participate in all grant specific meetings, care coordination collaboratives, and various community meetings as appropriate. Meet required grant deliverables as indicated.
  
  
  

Center Responsibilities:

• Participate fully in Center activities: staff meetings, work groups, innovative programs and projects, research activities.
  
  
  

Documentation:

• Communicate with providers via fax/email on progress of services.
• Document all care coordination activities in data bases as appropriate.
• Adherence to current HIPAA guidelines in insure patient/family confidentiality.
  
  
  

Education and Advocacy:

• Empower families to direct the care of their children within the medical home model (or other care delivery system) by formulating a care plan that promotes self-advocacy, networking skills, and culturally relevant services.
• Provides education, consultation, referrals, training and support to families and community providers through direct advocacy, technical training, and providing educational materials.
• Collaborates with colleagues in the Center for Care Coordination by providing information and technical assistance on cases, attending care management meetings, and assisting in the development of center policies and procedures
• Addresses issues that negatively impact cost and quality of care, liaisons with Connecticut Children’s Medical Center on-site and satellite programs, which serve children with special health care needs.
  
  
  

Demonstrates knowledge of the population-specific differences and needs of patients in appropriate, specific populations from neonate through adolescence and applies them to practice. Demonstrates cultural sensitivity in all interactions with patients/families and co-workers.

Demonstrates support for the mission, values and goals of the organization through behaviors that are consistent with the CT Children’s Behaviors.

Qualifications

Education and/or Experience Required:

• Education Required: Bachelor's degree in social work, Family and Human Development, Public Health, and related fields.
• Experience Required: Minimum of 3 years’ experience working with families and community system and may substitute for degree.
  
  
  

License and/or Certification Required:

• Valid CT Driver’s License; willingness to drive own vehicle throughout North Central Region and State of CT
  
  
  

Knowledge, Skills and Abilities:

Knowledge of:

• Community resources/social service organizations.
• Cultural diversity/awareness.
• Children, youth, and families.
  
  
  

Skills:

• Working with clinical providers as a part of the multi-disciplinary team
• Experience in working in clinical or community setting with children and families
• Excellent written and verbal skills
• Computer skills- data entry into program databases, including outcome metrics
  
  
  

Ability to:

• Ability to work with families of all ethnic and socioeconomic backgrounds.
• Ability to work independently; time management and organizational skills
• Competence in providing developmentally appropriate care and services
• Ability to work within boundaries of job description
• Ability to work collegially and collaboratively with all disciplines
• Excellent communication skills
• Bilingual (Spanish/English) preferred