Care Coordinator (PASSPORT)

This role is responsible for assessing the needs of individuals and coordinating services to support their health, safety, and independence. This role involves developing care plans, connecting clients with community resources, and advocating for their well-being while collaborating with families and service providers.

Primary Responsibilities

• Conduct in-home assessments and event-based visits.
• Conduct comprehensive assessments of an individual’s physical, emotional, social, and environmental needs.
• Develop and implement individualized care plans based on client needs, preferences, and available resources.
• Coordinate and monitor services such as home care, transportation, meals, housing, and medical appointments.
• Provide ongoing case management, including regular follow-ups, plan adjustments, and crisis intervention as needed.
• Advocate for clients’ rights and ensure they receive culturally competent, person-centered care.
• Maintain accurate and timely documentation in accordance with agency and regulatory requirements.
• Support clients and their families in understanding available options and navigating complex service systems such as Medicare and Medicaid.
• Participate in team meetings, training, and professional development opportunities.
• Adhere to program contact and visit schedule.