Position Summary:

The Care Coordinator for the PIWC-DC program facilitates the integration of behavioral and physical healthcare services for adults aged 55 and older with co-occurring conditions. The Care Coordinator ensures clients receive person-centered, holistic care, addressing medical, behavioral, and social determinants of health. This position is essential for program implementation, fostering partnerships, and ensuring service delivery aligns with individualized care plans.

Key Responsibilities

Client Advocacy and Support:

· Advocate on behalf of participants to ensure timely and culturally responsive services.

· Facilitate communication between providers, community organizations, and participants to ensure effective care delivery.

· Support participants in navigating healthcare systems and accessing social support services, including transportation and housing.

Care Coordination and Planning:

· Develop and maintain individualized care plans in collaboration with clinical staff, participants, and family members.

· Ensure participants receive comprehensive services across behavioral health, primary care, and social service providers.

· Work to remove barriers to care, addressing social determinants that impact client outcomes.

Collaboration with Partners:

· Establish and maintain partnerships with external agencies, including housing services, transportation providers, and healthcare organizations.

· Serve as a liaison between the care team and community resources to ensure participants transition smoothly between care settings.

Monitoring and Documentation:

· Track participant progress through regular contact, documenting care coordination activities and outcomes.

· Maintain accurate, timely records in compliance with HIPAA and grant reporting requirements.

· Provide regular updates to the Director of Clinical Practice on participant outcomes and program effectiveness.

Crisis Intervention and Support:

· Respond to participant crises by coordinating with emergency services and stabilizing support systems.

· Assist participants in accessing urgent care services to prevent hospitalizations.

Training and Development:

· Attend required trainings in trauma-informed care, cultural competency, and geriatric health to remain current on best practices.

Qualifications

· Bachelor’s degree in Public Health, Social Work, Psychology, or a related field; Master’s degree preferred.

· 3-5 years of experience in social services, behavioral health, or care coordination, preferably with older adults.

· Knowledge of community resources and services relevant to behavioral and physical health.

· Proficiency in Microsoft Office Suite and client management software.

· Ability to work independently and collaboratively in diverse and high-pressure environments.

Benefits:

• Medical, Dental, and Vision Insurance
• 401K Retirement and Life Insurance
• Hybrid work schedule
• 2 weeks accrued PTO
• 2 weeks accrued Sick Leave
• 8 paid company holidays
• Loan Repayment - Eligible employees can receive up to $50,000 in student loan repayment through the National Health Service Corps (NHSC)!
• Opportunities for professional development and growth!
• Mental health and leadership training
• Employee Assistance Programs (EAP)