Community Care Coordinator in Norfolk, Virginia at Childrens Hospital of The King's Daughters

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 individual’s and family’s comprehensive health needs. Reports to the Director of Case Management Services.

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.