People USA·Walden, New York
The coordinator connects Medicaid-enrolled individuals with mental illness or chronic conditions to essential community health and social services. Key duties include providing peer support, navigating complex systems of care, and documenting interactions in electronic records.
Organization: People USA – Non-Profit Peer Run Behavioral Health, Mental Health, Recovery, Wellness
Position: Orange County Health Home Care Coordinator
Job Location: Walden, NY
$24.50 per hour
The Orange County care coordinator will work with Medicaid-enrolled individuals, living with mental illness or multiple chronic conditions, to get connected to care and services in their local communities. By connecting high-risk Medicaid individuals to resources and supports, we aim to reduce duplicate services, reduce emergency department visits and inpatient admissions, and lower costs, thus improving the health and well-being of lives throughout Orange County. The population served has unmet mental heath, addiction or social determinant of health needs and does not typically engage with the traditional systems of care. The goal of the care coordinator will be to work with the participants and their care team in supporting individuals to identify goals and make connections to needed services.
Job
Responsibilities:
Assists participants with psychiatric diagnoses to participate in diverse, person-centered, self-directed services and meaningful activities that promote empowerment and robust recovery.
Collaborating with the SPOA (Single Point of Access) for referrals.
Maintains regular contact, outreach, curriculum development, group facilitation, counseling, mentoring, systems navigation, community oversight, and crisis support.
Provide Care Management outreach and engagement with eligible individuals in coordination with the Institute of Family Health, and Care Management Partners of Ulster County.
Provide screenings and evaluations using trauma-informed, person-centered skills with the Institute of Family Health’s service tools, along with individual advocacy, peer support and systems navigation.
Educates participants on useful health & wellness topics, including but not limited to Peer/Self-help, smoking cessation, and advocacy.
Resources, Recovery from Mental Health Challenges (from a Psychiatric Rehabilitation perspective), Wellness & Whole Health (SAMHSA’s Eight Dimensions of Wellness), Community Resources (across all domains of health, e.g.: physical, mental, substance use, socio-economic determinants of health), Trauma & Healing, Wellness Planning & Prevention (e.g. WRAP), Natural Supports (developing/maintaining).
Helps participants identify barriers to their recovery journeys or personal wellness, including access, quality of care, people’s rights, lack of basic needs, and stigma & discrimination.
Advocates for participants side-by-side to overcome identified barriers, making sure their voices are heard, and their decisions are understood and respected.
Builds peer-to-peer connections/relationships based on mutuality (shared lived experiences), empathy, and hope for recovery/wellness (peers-as-proof).
Assist Participants to identify & accomplish whole health goals related to the Eight Dimensions of Wellness (emotional, social, physical, environmental, financial, intellectual, occupational, spiritual).
Directly connects participants to the services and supports they need through direct bridging/linking (as opposed to referrals only).
Develops and maintains positive working relationships with other provider agencies, and local housing providers (landlords) within the county and its surrounding environments.
Documents all meaningful interactions with participants in electronic records software and maintains hard copies in participants’ files daily for audit purposes.
Responsible for submitting monthly reports on timely manner and attend related meetings.
Align all behaviors with core values that promote trauma-informed care, customer engagement and satisfaction, mutuality & empathy, and a philosophical commitment that everyone can and will recover.
Reports to - Director of Care Coordination & Advocacy Services
Market context
Behavioral health roles in New York are often in steady demand, especially for clinicians who can support diverse age groups and handle assessments or admissions. These positions can be competitive because employers commonly look for independent licensure, while also considering associate-level candidates with clear growth toward full licensure. Review the AI-summarized requirements and benefits here to save time, then confirm your licensure status and assessment experience before applying.
