Services for the Underserved

  • Care Coordinator

    Job Location US-NY-Brooklyn
    Behavioral Health
    Regular Full-Time
  • Position Overview

    The Care Coordinator will assume the care coordination responsibility for Chronically Ill clients identified from the NYS DOH (New York State Department of Health) list of high end users of Medicaid. Many of these clients will also have a co occurring disorder of mental illness and/or substance abuse.  They will conduct Community outreach to CIDP clients to enroll potential clients who are identified by the NYS DOH. They will be expected to provide care management and coordination of the plan of care for this specified population in need of intensive case management including health education and advocacy. They will also provide intensive care coordination in a medical setting to include illness management. Travel is required; 80%.



    • Help find, engage, and enroll clients from the NYS DOH list of eligible Brooklyn and Manhattan Medicaid beneficiaries who have chronic illness and possible mental illness and or substance abuse
    • Assure that clients reliably attend medical appointments at outpatient clinics
    • Assure that clients comply with prescription regiment
    • Write clear service plans and progress notes and maintain meticulous documentation of service visits
    • Provide services in the Clinical Home and in the community
    • Carry a caseload of clients, each of which is to be visited once and at least one service provided during the course of a calendar month
    • Coordinate ancillary care for clients to ensure continuous, comprehensive care
    • Collaborate with all members of the team, primary care and specialty doctors and all partners on a regular basis
    • Initiate appropriate referrals to additional services including home care and notify appropriate support staff of referral to ensure authorization
    • Assist clients to obtain access to transportation
    • Research, evaluate and recommend community resources to meet non medical needs of client (i.e. alternative resource programs, support groups and community support services.)
    • Work with Medical Home team inpatient providers, discharge planners and nurse partners to ensure efficient use of inpatient resources and a timely discharge to an appropriate setting
    • Facilitate and participate in client care conference for medical and peer review
    • Collaborate with mental heath and substance abuse care providers to ensure coordination of all services and integration of services
    • Work collaboratively with the ValueOptions Field Care Coordinator to provide and link clients to services that facilitate illness management
    • Provide verbal and written illness management educational protocols
    • Immediately reports serious incidents, serious incident allegations, incidents, or sensitive situations to supervisors. Completes incident reports in accordance with CIDP policy


    • B.A. degree in a related field required, graduate degree preferred 
    • 2 years experience in providing direct services to mentally disabled clients or in linking mentally disabled clients to a broad range of services essential to successfully living in the community
    • Basic knowledge of mental illness and serious emotional disturbances
    • Basic knowledge of treatment, rehabilitation, and community support programs as they relate to clients, families and staff
    • Bilingual English/Spanish preferred.  



    Company Overview

    Services for the UnderServed (S:US) believes every New Yorker has the right to lead a life of purpose. Since 1978, S:US has been turning this belief into reality by advocating for people with life circumstances marked by homelessness, intellectual/developmental disability, behavioral health and addiction challenges, poverty, criminal justice involvement, and trauma. Our dedicated workforce of 2,400 provides services and supports to transform the lives of 35,000 individuals and families in New York City and Long Island. Learn more about S:US, our mission, and values by visiting


    Benefits Overview: We offer attractive compensation with comprehensive benefits including: Medical/Dental/Prescription/Vision/Life Insurance; 403(b); Credit Union; FSAs; Short-and-Long-Term Disability; Transportation Plan; Generous Paid Vacations and Holidays


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