Community Care Coordinator

GENERAL SUMMARY The Community Care Coordinator is responsible for coordinating the medical management care plan to meet the individual/caregiver needs, promoting quality, cost effective outcomes. Work involves educating and empowering individual/caregiver toward self-care and independence. The Community Care Coordinator collaboratively works to carry out the process of assessment, planning, facilitation, care coordination, evaluation and advocacy options and services to meet the individuals and familys comprehensive health needs. Reports to the Director of Case Management Services. ESSENTIAL DUTIES AND RESPONSIBILITIES Provides care coordination services consistent with the Title V CYSHCN definition and core outcomes, including access to a medical home, adequate insurance coverage, and community-based services. Conducts comprehensive assessments addressing medical, developmental, psychosocial, educational, and social determinants of health. Develops and maintains individualized, family-driven care plans in collaboration with families and multidisciplinary partners. Coordinates services across healthcare, behavioral health, education, early intervention, social services, and community systems. Promotes culturally responsive, trauma-informed, and linguistically appropriate services. Collaborates with family leaders, parent advisory groups, and family organizations as appropriate. Serves as a liaison between families and providers to reduce fragmentation of care and improve service integration. Supports care transitions, including hospital-to-home, early intervention to school-age services, and transition from pediatric to adult systems of care. Contributes to continuous quality improvement efforts within the Title V CYSHCN system. Participates in multidisciplinary team meetings, case conferences, and care planning sessions. Maintains timely, accurate, and confidential documentation in accordance with program requirements, regulatory standards, and professional practice guidelines. Tracks outcomes, service utilization, and quality indicators as required. Adheres to applicable federal, state, and local regulations, including HIPAA and mandated reporting requirements. Participates in outreach, education, and program development activities as assigned. Prepares quarterly reports for submission to the Virginia Department of Health as per direction of Program Manager in compliance with the contract. Performs all other duties as assigned. LICENSES AND/OR CERTIFICATIONS Required Licenses and/or Certifications Must earn case management certification within one year of eligibility from ACM, CCM or ANCC accrediting organizations. MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS Required Education and Experience MSW with three years of pediatric social work experience or RN (BSN preferred) with five years pediatric experience and three years case management experience or an advanced practice licensed pediatric nurse practitioner required. Experience with community-based case management and outreach. Experience working with diverse communities, families, or public health programs. Experience with data entry, reporting systems, or electronic case management tools and electronic health records. Preferred Education and Experience Experience working with children with chronic conditions or complex medical health needs and disabilities is strongly preferred. Required Knowledge, Skills and Abilities Strong understanding of child development, chronic health conditions, and family systems. Knowledge of Medicaid, CHIP, special education services, early intervention, and community-based support systems preferred. Excellent communication, advocacy, and interpersonal skills. Ability to work independently while managing a diverse caseload. Proficiency in use of personal computers and Microsoft software, electronic medical records, and database software. Commitment to equity, inclusion, and family-centered practice. Must be able to plan, manage, and establish a professional working environment within areas of responsibility. Must possess the ability to identify problems and implement solutions for operational and organizational issues. Interpersonal skills necessary in order to communicate effectively with other professionals. Preferred Knowledge, Skills and Abilities Bilingual (Spanish/ English) verbal and written skills are preferred. WORKING CONDITIONS Community-based requiring home and agency visits and local travel required. Primarily community-based with home visits, school meetings, and collaboration across multiple settings. Combination of community based and office/remote work as approved. PHYSICAL REQUIREMENTS Click here to view physical requirements.