Care Coordinator

Position Description

The Care Coordinator (CC) serves as a link between the intake department and the assigned Care Manager. They are the first point of contact for all new clients and act as a focal point of communication between clients and their assigned Care Manager. The Care Coordinator will ensure clients receive the care they need during the transition from intake until they are assigned a Care Manager. The Care Coordinator's primary responsibilities include initiating contact with newly enrolled clients, creating the initial Care Plan, and identifying the goals outlined during the intake process. Additionally, under the supervision of the Data Manager, the Care Coordinator is tasked with conducting diligent search activities for clients who have become disengaged. When the Intake Coordinator is unavailable, the Care Coordinator handles intakes. As a direct care provider, the Care Coordinator assists newly enrolled clients in accessing immediate services identified during the intake process, such as connecting them with primary care and mental health providers or food resources. Furthermore, the individual in this role begins gathering some of the information necessary to complete the initial assessment. The Care Coordinator also conducts home visits or fieldwork as required by the program's needs.

Th is position operates on a hybrid schedule, with four days in the office and one remote workday.

Essential Job Functions

• Reach out to newly enrolled clients via phone within 48 hours of assignment to introduce yourself and initiate the care process.
• Schedule initial face-to-face visits with newly enrolled clients within the week of their assignment to establish rapport and assess their needs.
• Develop personalized care plans in collaboration with clients and their families and ensure all required signatures are collected.
• Maintain regular communication with clients to monitor progress and adjust care plans as necessary.
• Liaise with other healthcare providers and community resources to ensure comprehensive care.
• Gather necessary information for the care manager to initiate the assessment.
• Assist clients in obtaining urgently needed services during the intake process.
• Refer clients who are not connected to care to appropriate providers, such as primary care physicians (PCPs), psychiatrists, cardiologists, oncologists, and physical therapists.
• Conduct fieldwork as needed, including home visits and accompanying clients to clinic appointments to ensure their well-being.
• Help clients navigate the healthcare system, find the right providers, schedule appointments, and connect them with community resources such as transportation, housing resources, meal delivery, and support groups.
• Perform comprehensive Due Diligence Search (DDS) activities, which involve making regular phone calls to clients who have lost contact, reaching out to emergency contacts, conducting inmate lookup searches, and documenting all findings in the Foothold Care Management (FCM) system.