Hybrid Intake and Care Integration Coordinator presso Villa of Hope

Intake and Care Integration Coordinator

Villa of Hope helps youth and families rebuild relationships, recover from trauma and renew Hope for their future.

JOB TITLE: Intake and Care Integration Coordinator
 DEPARTMENT: Community Services – Adult Health Homes
SUPERVISOR: Program Manager

POSITION GRADE: 80 [ salary range: 19.50hr-33hr commensurate with education and experience]                   

GENERAL JOB DESCRIPTION:
 Under the direction of the Program Manager, the Adult Health Homes Intake and Care Integration Coordinator serves a blended role, managing incoming Health Home referrals and facilitating enrollments, while also providing ongoing care management services for a flexible, low-volume caseload. The balance between intake coordination and care management will shift depending on referral volume and caseload needs.

This position requires strong interpersonal and engagement skills, the ability to work collaboratively across systems, and a deep commitment to supporting individuals with complex needs. The Coordinator will be a key point of contact for referring agencies, support clients through the intake and enrollment process, and provide integrated, person-centered services to ensure continuity of care.

All responsibilities are carried out in alignment with Villa of Hope’s Mission, Vision, Values, Guiding Principles, and Strategic Plan.

ESSENTIAL FUNCTIONS:

• Exercises full compliance with the agency’s code of conduct, all agency policies, and procedures. 
• Maintains confidentiality and security for all client and staff related materials and/or records. 
• Regularly practices adherence to the program/agency standards, and ensures documentation/policy requirements are being followed. 
• Demonstrates, promotes, and practices cultural competency towards clients through respect and understanding. 
• Recognizes and embraces the diversity of teams, supports and develops the strengths of each individual adult and their family. 
• Consistently maintains positive relationships with clients, families, other service providers in the community, and coworkers. 

Intake Coordination

• Serve as the primary contact for incoming Health Home referrals and complete all client enrollments in accordance with HHUNY and DOH guidelines.
• Engage prospective clients using person-centered, flexible approaches (in-home, in-community, office-based, or via phone/video/Fluix).
• Must be comfortable and confident in traveling throughout the Rochester community and Monroe County area and driving often. 
• Will have designated office hours to meet with clients and providers as needed. 
• Clearly explain program services and eligibility criteria to clients and referral sources, addressing any barriers to enrollment.
• Must follow intake checklist and initiate documentation in Netsmart within 24 hours of engagement and ensure timely completion of all intake materials.
• Conduct initial ACES and SDOH assessments and gather clinical, behavioral, and social history to support transition to ongoing care management.
• Collaborate with the Program Manager on case assignments based on client needs and team capacity by participating in weekly supervision. 
• Track all referral and intake activity using Excel and maintain accurate records of enrollment status.
• Promote program awareness through outreach events, presentations, and scheduled on-site hours at partner locations (e.g., Hope Place, shelters, treatment programs).
• Maintain strong working relationships with hospitals, mental health providers, shelters, and other referral partners.
• Support onboarding of new staff by providing coaching on the intake process and attending initial visits when needed.

Care Management Integration

• Maintain a small, flexible caseload of Health Home clients; caseload size will vary based on enrollment needs, including short-term coverage of other caseloads as needed during staff transitions or absences.
• Conduct comprehensive assessments, develop strength-based, person-centered Plans of Care, and coordinate care team meetings.
• Provide monthly face-to-face visits and ongoing care management services tailored to each client’s physical, behavioral, and social needs.
• Link clients to needed community supports, including mental health services, housing, medical care, and substance use treatment.
• Inform and educate clients and families around their diagnoses, treatment options, and impact on home and community.
• Monitor risk and safety concerns, and assist in creating individualized safety or support plans.
• Will document all client contacts and assumes responsibility for maintaining clinical records, ensure all documentation is accurate, timely, and compliant with program standards.
• Participate in regular supervision, team meetings, and professional development activities.

MINIMUM QUALIFICATIONS:

• A Master’s degree or A Bachelor’s of Arts or Science are preferred, 
• Or An Associate’s Degree with 1 year relevant experience in the Human Service, Health Care, or Mental Health fields. 
• A strong knowledge of Adult Mental Health preferred. Minimum of 2 years of experience working with adults with mental health or complex needs; experience in Health Homes preferred.

SPECIAL SKILLS

• Valid NYS driver’s license and access to reliable transportation.
• Flexibility to work occasional evening hours.

PHYSICAL REQUIREMENTS: 

• The following lists physical demands an employee will perform on a regular basis: standing, walking, sitting, bending, stooping, squatting, kneeling and climbing stairs. 
• Ability to drive 
• Ability to walk short distances 
• Ability to use stairs 
• Ability to leave a location quickly

COMPETENCIES:

• Leading Self - Character and Courage (Integrity and Trust)
• Leading Others - Customer Focus, Coaching & Engagement
• Leading the Organization -Commitment to Diversity, Inclusion, Justice, and Equity
• Systems Collaboration and Communication