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Adult Health Home Care Coordinator

790 Ridge Rd, Lackawanna, NY 14218, USA Req #383
Tuesday, June 25, 2024

ūü§ĚLooking for a rewarding career not sitting at a desk all day? Do you like doing outreach and speaking to the community? Then the role of a Health Home Care Coordinator is perfect for you! This role is multifaceted and requires strong organizational skills, clinical knowledge, empathy, and the ability to work effectively with diverse populations. It aims to improve patient outcomes by facilitating comprehensive and integrated healthcare services! 


  • Paid Holidays
  • Generous Paid Time Off (PTO) 
  • Casual dress code
  • Health, dental & vision insurance options
  • Paid Employer sponsored life insurance
  • Supplemental insurance programs for additional life insurance, short-term disability, accident & cancer insurance
  • Up to $600 every year for completing biometric health screenings on a single health insurance plan & up to $1,200 if a spouse completes too!
  • Tuition Reimbursement
  • Employer qualifies for Public Student Loan Forgiveness (PSLF) 
  • Free dental insurance (for Full Time employees and their families)

Responsible to: Director or Health Home Supervisor

Job Summary: 
The Care Coordinator applies the essential activities of case management which include assessment, planning, coordination, monitoring and evaluation with the core components (Comprehensive Case Management, Care Coordination & Health Promotion, Comprehensive Transitional Care, Patient & Family Support and Referral to Community & Social/Support Services) to patients within the Center for Care Coordination. The Care Coordinator provides care coordination for patients with a diagnosis of Serious Mental Illness (SPMI), substance use disorder, and other chronic health conditions. The Care Coordinator is responsible for the following outcomes:  Reduce utilization associated with avoidable and preventable inpatient stays; reduce utilization associated with avoidable emergency room visits; improve outcomes for persons with mental health illness and/or substance use disorders; and improve disease-related care for chronic conditions. If educational and necessary work experience qualifications are met, Care Coordinators will work with patients enrolled in the Health and Recovery Plans (HARP), including assessing patients using the HCBS Eligibility Assessment, communicating with MCOs regarding Plans of Care, and coordinating referrals to HCBS providers under HARP. The Care Coordinator reports directly to the Director of Care Coordination or the Health Home Supervisor, who shall determine specific responsibilities of the position. These responsibilities may be revised, as necessary, with proper notification and training provided, where appropriate.

Essential Job Duties: 

  • Delivers core services in accordance with Health Home standards to patients on assigned caseload. Achieves monthly and quarterly productivity expectations.
  • Completes a comprehensive assessment within 60 days of patient’s enrollment and an annual reassessment inclusive of medical, behavioral, social, and rehabilitative needs. 
  • Completes individualized patient-centered care plan with the patient within 60 days of enrollment and updates monthly to identify patient’s needs and goals and includes family members and other social supports as appropriate. The Care Plan is also amended annually. 
  • Completes and amends patient crisis plan. Coordinates with service providers and health plans as appropriate to secure necessary care during a crisis, share crisis intervention and emergency information. 
  • Coordinates with multidisciplinary team on patient’s care plan, including but not limited to the primary care physician and/or any specialists involved in the treatment plan.
  • Links and refers patients to needed services to support care plan including medical and behavioral health care, patient education, entitlement programs, self-help groups, and recovery and self-management. Attends appointments with patient as necessary. 
  • Conducts diligent search activities to ensure patient engagement and to assess on-going emerging needs in order to promote continuity of care and improve health outcomes.
  • Conducts annual case review with interdisciplinary team to monitor and evaluate patient status.
  • Follows up with patient upon notification of ER or inpatient admission and/or discharge and facilities transitions of care within 24-48 hours.
  • Advocates for interpretation services and utilizes translation line as needed
  • Maintains complete, current, and accurate patient charts that comply with the Health Home Standards.  
  • Documents all patient-related encounters and chart activities in a progress note within 24-48 hours, including encounters with patient, providers, and other members of the care team. Attempted contacts and completion of documentation (such as the assessment and care plan) must also be documented in the form of a progress note. 
  • If applicable, completes the Eligibility Assessment with patients enrolled in Health and Recovery Plans (HARP). 
  • If applicable, enters data collected from the Eligibility Assessment into the NYS Health Commerce System. Submits the results of the Eligibility Assessment to MCOs for approval and service determination.  
  • If applicable, completes the HARP Health Plan Summary with HARP enrolled patients, communicates with MCOs and Home and Community Based Services (HCBS) providers to ensure referral and linkage to services outlined in the Health Plan Summary. 
  • Enters data timely and accurately to promote patient care delivery and participates in ongoing QI/QA activities and training to improve patient experience and increase data quality where needed.  Maintains and protects sensitive information in enterprise systems and uses/shares data in compliance with Information Governance and Security Policies.
  • Attends initial orientation, completes required annual trainings, and other trainings to strengthen skills and improve program outcomes.
  • Actively checks work emails, reads all company communications and stays up to date with organizational and department specific announcements. 
  • Adheres to policies regarding working hours, break periods and proper use of the UKG payroll and benefits system. 
  • Maintains adherence to Corporate Compliance policies; promptly reports any violations to their supervisor, the Corporate Compliance Officer, or anonymously to the Corporate Compliance helpline at: (716) 828-7654.
  • Other duties as requested


  • Fluent in reading, writing, and speaking English. 
  • Possess valid driver’s license and an insured, dependable car to use for work-related activities, and willingness to travel throughout all service counties.
  • Must be able to communicate clearly and professionally verbally and in writing. 
  • Ability develop and maintain written documentation, including progress notes, assessments, and care plans.
  • Proficient with computers and Microsoft Office Suite (Outlook, Word) or related software.
  • Strong ability to activity engages and quickly build rapport with patients living with mental illness, substance use, and/or chronic medical conditions, and with their care team. 
  • Ability to provide education about substance use disorder and mental illness, as well as various treatment options.
  • Ability to provide guidance on how to manage or cope with substance use disorder relapse and maladaptive behaviors.
  • High level clinical assessment skills, ability to provide emotional support, crisis planning and intervention, and problem-solving skills training.  
  • Adaptable and flexible to change.
  • Ability to develop person-centered and harm reduction-based care plans to promote progressive movement towards patients’ goals. 
  • Ability to work effectively in a team environment and be receptive to feedback
  • Excellent interpersonal relationship and customer services skills with patients and providers to ensure that patient needs are met, including transitions of care. 
  • Excellent organizational and time management skills with proven ability to meet deadlines. 
  • Ability to work independently and willingness to learn on the job. 
  • Ability to work effectively with people from diverse cultures and socioeconomic backgrounds.
  • Critical thinking ability and decision-making skills. 
  • Ability to link and refer patients to community resources and providers, while also collaborating with the care team. 
  • Understanding of person-centered/recovery-oriented planning, and harm reduction, and sensitivity to HIV/AIDS, LGBTQ lifestyle issues, and addiction issues are essential. 
  • Ability to function well in a high-paced and at times stressful environment.
  • Uphold OLV Human Services Core Values and principals.

Minimum Education Required:
Bachelor’s degree in health, human or education services and one (1) year of qualifying experience*           
Associate’s degree in health, human or education services and two (2) years of qualifying experience*
*Qualifying Experience: verifiable full- or part-time experience in care coordination with the following populations:   persons with a chronic illness, and/or persons with a history of mental illness, homelessness, or chemical dependence. Experience with families preferred.
Bachelor’s degree in health, human or education services and two (2) years of qualifying experience** allows Care Coordinator to work with HARP population.

Minimum Experience Required:   
**Qualifying experience, as defined by NYS Department of Health (to work with HARP population):
Provides direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or
Linking individuals with Serious Mental Illness, developmental disabilities, or substance use disorders to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services).

License/Registration/ Certifications Required:  NYS Driver's License

Training Requirements:  

  • New Hire Orientation
  • All HHUNY(Health Home of Upstate New York) related training

Physical Requirements: 

  • Mobility sufficient to attend to patient services activities in and out of the office including home visits, patient appointments and other patient-related business.
  • Visual acuity sufficient to conduct thorough and effective patient interviews assessing both verbal and nonverbal cues.
  • Auditory acuity sufficient to communicate in-person and over the phone.
  • Ability to work normal full-time hours with usual and customary breaks.
  • Ability to lift up to 25 pounds without restriction to safely manage program supplies and equipment.

Other details

  • Job Function Non-Essential
  • Pay Type Hourly
  • Min Hiring Rate $21.37
  • Max Hiring Rate $28.52
  • Travel Required Yes
  • Required Education Associate Degree
Location on Google Maps
  • 790 Ridge Rd, Lackawanna, NY 14218, USA