The Bilingual Care Coordinator provides case management services to Health Homes clients with chronic illnesses, links to full range of needed services, ensures the coordination of these services through advocacy, and promotes integration of community providers across Long Island and Queens. The Care Coordinator promotes client compliance to medical and behavioral health services and addresses barriers to connecting and maintaining care while encouraging self-sufficiency and empowerment.


  • Coordinate services for a caseload of approximately 50 clients.
  • Conduct Intake and Assessment of new clients and develop a service plan based on their health care and social service needs according to Health Homes standards and time frames. Obtain consents.
  • Conduct Reassessments and update Service Plans goals. Review outcomes to care plan annually or following significant events.
  • Case conference with multidisciplinary team and or any specialists involved in the care plan/needs/goals on a bi-annual basis/as needed.
  • Monitor/support/ accompany the client to scheduled medical appointments to ensure continuity of care; advocate with service provider as necessary.
  • Provides telephonic as well as face to face outreach, engagement and service planning in the field.
  • Assist clients in maintaining financial entitlements (including Medicaid eligibility).
  • Maintain record of client’s entitlement recertification date and other related reports in an organized, timely and accurate manner as per policy and procedure guidelines.
  • Conduct on-site crisis intervention (including suicide intervention and family support). Share crisis intervention with appropriate provider.
  • Follow up with hospitals/ERs upon notification of a client’s admission and /or discharge to/from an ER/residential/hospital/rehabilitative setting.
  • Establish regular meetings with Health Homes management team to discuss caseload.
  • Work as part of a Care Coordination team; attend and participate in team, network and committee meetings to provide input/feedback around psychosocial conditions/comorbidities to review client status.
  • Attend trainings and workshops for staff development, as directed.
  • On call coverage may be required.
  • Collaborate/coordinate with community-based providers to support effective utilization of services based on client/family need.
  • Ensure documentation in electronic medical record system is in accordance with agency standards and program guidelines.
  • Complete required reports, progress notes and related documentation, in a timely fashion.
  • Refer client/family to peer supports, support groups, social services, entitlement programs.
  • Build and maintain relationships with appropriate service providers. For example, Department of Social Services, Social Security Administration, and other community-based programs.
  • Maintain quality assurance systems to ensure that services are in place for clients and documentation is complete and up to date. Participate in agency quality assurance program.
  • Assure client information is kept confidential at all times.


Master’s or Bachelor’s degree in Social Work or health/human or education services and one year of qualifying experiences in the health field; or Associate’s degree in health/human service related fields and two years of qualifying experience in the health field.


  • Demonstrate competency in written, verbal and organizational skills to present and document records in accordance with program standards.
  • Working knowledge of electronic health record systems, computer skills, proficient in Word, Excel.
  • Active listening skills needed to document accurate information.
  • Working knowledge of interdisciplinary planning process and the development of an individualized patient centered plan of care.
  • Knowledge of Medicaid, Social Security and other entitlements preferred community resources.


Hauppauge, full time position

AAP/EEO Statement:
PSNNY is an EOE (Equal Opportunity Employer); all decision are made without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, gender identity, or any other legally protected status.

Interested applicants should email their resumes and salary requirements to: