Care Coordinator

Your responsibilities will include :

• Transitional Care : Support clients as they move from hospital or rehab settings back into the community—ensuring continuity, safety, and support every step of the way.
• Care Plan Development and Implementation : Conduct initial and ongoing assessments of clients to document strengths, needs, goals and resources.
• Connectivity to Care : Schedule and coordinate timely follow-up with primary care and behavioral health providers.
• Addressing Gaps in Care : Identify missed appointments, medication lapses, or unaddressed needs—and take proactive steps to close the loop.
• Social Determinants of Health : Connect clients with resources such as housing, food security, transportation, and income / benefits support (SSI / SSD, SNAP, HEAP, etc).
• Collaborative Care : Work with a network of providers and support agencies to build individualized, person-centered care plans that truly make a difference.
• Engagement : Provide face to face outreach, engagement, and service planning in the field including clients' homes, shelters, and hospitals
• Documentation

Maintain documents, records, and other related reports in an organized, timely and accurate manner as per policy and procedure.