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Job Description

Provides outreach and enrollment services to children presumed to meet eligibility requirements of New York State’s Children’s Health Home program.  Gathers assessments and enters documentation that confirms eligibility and identifies areas requiring supportive services.  Works with children, families and service providers to create a comprehensive Plan of Care (POC), identify additional service providers as necessary, and coordinate the continuing involvement of families and service providers in the execution of the plan.  Documents progress and arrange for eventual transition between health homes as necessary, or from health homes to other levels of service following changes in eligibility.

Essential Duties & Responsibilities: 

  • Document all case activity, including outreach, consent development and assessment, plan development, client progress and transition arrangements.
  • Administer CANS-NY assessment, updating periodically.
  • Develop a comprehensive, family-driven youth-guided Plan of Care (POC).
  • Inventory and coordinate existing services relevant to the POC, identifying and securing additional services as appropriate.
  • Convene and conduct quarterly meetings to review progress, update POCs, and confirm continuing client eligibility.
  • Provide education to family and child concerning the nature and desired effect of services, along with information concerning conditions being treated.
  • Assist families and children in the acquisition and maintenance of public benefits e.g., financial, educational, social, and community services.
  • Provide monthly Health Home services for children based on acuity level as per DOH requirements.
  • Assure responsible transition of client service into and out of Health Home care, between child and adult health homes, and between inpatient and community care as appropriate.
  • Participate in various trainings, including but not limited to:  CANS-NY administration; family-driven, youth-guided, trauma-informed care; LGBTQ, safety in community, and cultural competency.
  • Participatory member of staff and supervisory meetings.
  • Additional duties as assigned within scope of job description.


  • Bachelor’s degree in human services field with 2 years’ relevant experience or Master’s degree in human services field with 1 year of relevant experience
  • Relevant experience is defined as serving children and families in child welfare, developmental disabilities, behavioral health, primary health care, or social services
  • Excellent engagement and organizational skills in order to deliver family-driven, youth-guided services
  • Ability to work independently and collaboratively
  • Valid NYS driver’s license with driving record acceptable to BHSN insurance carrier required
  • Experience coordinating and participating in team settings preferred
  • Strong written and verbal communication skills

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