Health Homes Care Coordinator


JOB TITLE: Health Homes Care Coordinator

DEPARTMENT: Health Homes Administration (HHA)

LOCATION: Niagara Falls, N.Y.



To coordinate services with the Health Homes for the purpose of decreasing high risk medical and/or behavioral health costs for individuals being serviced in this Health Home.


  1. Provide services on a regular basis to individuals referred.
  2. Coordinate Western New York Independent Living, Inc. (WNYIL) staff to meet established benchmarks in required amount of time, set by the Health Homes, for individuals being served.
  3. Maintain, encourage and identify, individuals being served by WNYIL, Inc. in a Health Home, and the need for attendance at medical appointments, including appointments upon discharge from a hospital.
  4. Ensure WNYIL, Inc. staff follow-through on decreasing or eliminating barriers that individuals may face in keeping appointments through coordination with WNYIL, Inc. direct service staff.
  5. Coordinate WNYIL, Inc. direct service staff to collaborate with the individuals’ community and family supports to meet identified social needs.
  6. Coordinate with WNYIL, Inc. direct service staff to follow through with Quality Assessments and Improvements at each visit.
  7. Coordinate WNYIL, Inc. direct service staff to develop and implement Person Centered Plans that involve the individuals’ social supports with family and friends as well as other identified community supports.
  8. Enter all required data into all required program reporting databases (including but not limited to, Care Plans, referrals, progress notes and assessments).
  9. Maintain a caseload of 45-75 individuals per month.
  10. Make contact with all individuals at least monthly.
  11. Verify Medicaid eligibility for assigned caseload monthly.
  12. Track Medicaid recertification dates and assist individuals with recertification, if necessary.
  13. Assist individuals with change of provider/vendor, if necessary.
  14. Finalize documents in all required program reporting databases.
  15. Assist with Health Homes outreach if necessary.
  16. Accurately document consumer services and required paperwork in WNYIL’s Service Performance Record (SPR) database, as well as the Electronic Consumer Record (ECR), within two (2) working days of the date of service.
  17. Attend Agency’s in-service training and staff meetings as well as any other Agency related activities as required.
  18. Participate in maintaining a neat, clean and safe work environment.
  19. Perform other job-related duties as assigned by the supervisor.


  • Must possess a bachelor’s degree in one of the following areas: Child & Family Studies, Community Mental Health, Counseling, Education, Nursing, Occupational Therapy, Psychology, Recreation, Recreation Therapy, Rehabilitation, Social Work, Sociology or Speech and hearing.


NYS licensure and current registration as a Registered Nurse AND a bachelor’s degree


Bachelor’s level education or higher in any field with five (5) years’ experience working directly with persons with behavioral health diagnosis OR a CASAC.

  • Must have a master’s degree in one of the fields listed above, with one (1) year experience


Bachelor’s degree identified above with two (2) years’ experience in the following: either providing direct services to persons diagnosed with mental disabilities, developmental disabilities, alcoholism or substance abuse.


Linking persons who have been diagnosed with mental disabilities, developmental disabilities, alcoholism, or substance abuse to a broad range of services essential to successfully living in a community setting.


  • Must have intermediate level of knowledge of computers including the use of Excel spreadsheets, databases, word processing and networks.
  • Bilingual candidates encouraged to apply.
  • Netsmart/MAPP database experience preferred.
  • Perform in a professional, conscientious, and efficient manner for the purpose of ensuring a better quality of life for persons with disabilities.


WORK ENVIRONMENT: Office/ Community

PHYSICAL DEMANDS OF THE JOB: Sitting for extended periods of time.
Occasional lifting of not more than 15 pounds.

HOURS / SHIFTS: 37.5 – 40 hours per week. M – F 8:30 a.m. – 5:00 p.m.
Overtime rarely required.

CLASSIFICATION: Full-time, salary, non-exempt, Professional staff.
Range: $37,000  - $42,000

BENEFITS: Agency-provided group health insurance.
Vision, dental, life, supplemental insurances available.
PTO and paid holiday packages.
403(b) retirement with Agency match.
Employee Assistance Program

OTHER: Western New York Independent Living, Inc. values our employee safety and follows all recommended NYS required Infectious Disease Prevention Protocols.
Western New York Independent Living, Inc. is an Equal Opportunity Employer.
Reasonable accommodations will be made for people with disabilities.
Western New York Independent Living, Inc. is a scent-free Agency.


Closing date: May 16, 2024

Cover letter and resume required to:

Tina Brown, CHRCO
WNY Independent Living, Inc,
3108 Main St.
Buffalo, N.Y. 14214