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Care Coordinator - Bronx in Bronx, NY at Pride Health

Date Posted: 7/24/2018

Job Snapshot

Job Description

JOB TITLE: Care Coordinator

DIVISION: Treatment and Recovery

IMMEDIATE SUPERVISOR: Health Home Supervisor


The Care Coordinator functions as a member of an interdisciplinary team to provide care coordination to a caseload of severely mentally ill adults with multiple medical comorbidities and/or co-occurring substance abuse disorders and/or medically ill individuals.  Advocates for and supports the client, engages with community agencies/health care providers and others on his behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations. Provides clinical support to the Team by providing consultation, education, information around psychosocial and/or substance abuse conditions, interventions, resources to maintain focus on outcomes and best practices.


  • Conducts initial and ongoing assessments of assigned clients to document strengths, needs, goals, and resources.
  • Participates in the development/documentation /review and update of client centered comprehensive integrated, interdisciplinary care plan in consultation with   other team members to ensure focus on desired outcomes.
  • Maintains effective communications with clients, primary care physicians, substance abuse, and mental healthcare providers, family, collateral resources and other Agency staff on behalf of clients.
  • Maintains documents, records, statistics, and other related reports in an organized, timely, and accurate manner as per policy and procedure.
  • Coordinates care planning with other providers of services/ resources to ensure goal directed, collaborative care, including care transitions.
  • Works as part of a Care Coordination team; attends and participates in team meetings to provide input/feedback around psychosocial and medical conditions conditions/comorbidities to review client status, update plans and goals, review outcomes to further program goals.
  • Acts as a resources/consultant to all team members on psychosocial, medical and/or substance abuse issues and resources.
  • Provides telephonic as well as face-to-face outreach, engagement, and service planning in the field.
  • Acts as a linkage to community services including medical, behavioral, residential, entitlement and any other needed services per interdisciplinary care plan.
  • Monitors overall service delivery to clients to ensure coordination and continuity; advocates with service providers/resources as needed.
  • Provides crisis intervention and follow-up.


  1. A bachelor’s degree 

AND two years of experience:

  1. In providing direct services to people with Serious Mental Illness, developmental disabilities, or substance use disorders; or
  2. In 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).

A master’s degree in one of the qualifying education fields may be substituted for one year of experience