Care Coordinator

REPORTS TO: Program Manager

SUPERVISES : Peer Intern(s)

EMPLOYMENT STATUS : Full - time Regular, Non - Exempt

PRIMARY FUNCTION: Coordinating care and providing guidance to clients with complex psychiatric

and/or comorbid medical conditions. Develops effective interpersonal relationships with clients and

works collaboratively with the interdisciplinary care team to improve health outcomes. Utilizes

internal and community resources to educate clients and form a care plan with specific health

outcomes.

DUTIES & RESPONSIBILITIES:

• Work collaboratively to ensure thorough and timely monitoring and progress of up to 60

clients toward their Care Plan goals.

• Review Care Plan monthly and check intensity level of identified client to confirm service

needs are met.

• Interact with client and /or client caregivers to guarantee continuity of care, patient

adherence to care plans, and identification of barriers preventing adherence to care plan.

• Track all medical, behavioral , substance use , and other network referrals made for clients .

F ollow up on referrals and scheduled appointments, through accompaniment when necessary.

• Provide outreach via phone to clients to ensure appropriate follow up regarding self - care,

medication refills, Care Plan adherence, scheduled office visits, test results/lab work, and all

other pertinent psycho - social issues.

• P hysical ly outreach clients who have been non - adherent to necessary treatment

appointments or have missed appointments for initial visits with new providers. Make

reminder phone calls to patients for all appointments.

• Ensures that relevant care team members receive important client alerts, including ER visits,

hospitalization admission/discharge information and other urgent care notifications.

• Track client progress through a combination of written work, agency databases, health home

data system , and case conferences with the Care Team. Document and maintain case records

in the agency database . C omplete all data entry within a 24 - hour time frame.

• Become familiarized with service providers in the Health Home network and maintain a

comprehensive list of contact information for key personnel within the network.

• Always represents Alliance with the highest level of professionalism and respect.

• Monitor client entitlements, insurance, and other benefits to ensure they remain active and in

place . Assists with reinstatement of said benefits.

• Participate in initial and ongoing training as necessary to maintain a level of knowledge

related to serious physical ailments as defined by Health Home regulations.

• Attend all scheduled All - staff Agency, Program, and Bucket meetings or any other meeting

your supervisor or the funder decides.

• Commitment to continued learning

• Attend, In - Person, a minimum of two annual agency events for clients (i.e. World AIDS Day,

PREP Graduation, Poetry Reading, etc.) Thanksgiving and Holiday party do not qualify!!

• Fundraise or donate (give or get) $150 annually.

• Other duties as required to meet the mission of the agency and Client Services department.

QUALIFICATIONS : Bachelor’s degree in health or human services field required and one -year

working with an underserved population through employment, volunteer work, and /or internships;

Experience with chronic disease and HIV/AIDS , substance use , m ental Ill ness, or the Lesbian, Gay

Bisexual and Transgender (LGBT) population . Bi - lingual in Frenc h, Creole, or Spanish preferred.

Excellent written and verbal communication skills required. Belief in Alliance’s mission and work is

desirable. Strong commitment to diversity, equity, and inclusion required. COVID - 19 vaccination

required.

LOCATION : CASA & Midtown

STARTING SALARY: $45,000