IDD Care Coordinator

The Intellectual/Developmental Disabilities (I/DD) Care Coordinator is responsible for providing comprehensive care coordination and monitoring (treatment planning case management) to Cardinal Innovations’ enrollees having a primary Intellectual/ Developmental Disability with or without a secondary Mental Health or Substance Use need based on each enrollee’s unique circumstances. The I/DD Care Coordinator is responsible for connecting enrollees to appropriate services and ensuring they remain connected by identifying and addressing needs and barriers to treatment and engagement.

Essential Functions

– Identification of clinical needs, affirmation of level of care through case review, and the exercise of clinical judgment in communication with providers
– Provision of assistance with and oversight of the development of Individual Support Plans (ISPs) and monitoring of the provision of services under those plans
– Performance of tasks associated with care management planning to include:
– Utilizing person-centered thinking and planning tools to gather accurate and appropriate information needed to support the member
– Providing education and support to members in learning about and exercising rights
– Conducts a thorough clinical review of all newly assigned cases to become familiar with member’s current clinical needs and desired supports.
– Continually assessing member’s preferences, dreams and aspirations through ongoing dialogue with the member and those who know them best
– Ensuring that members/legally responsible persons are informed of services available, and provides clinical evaluation of service options (e.g. Individual/Family Direction for Innovations participants) and/or processes (e.g. requirements for specific service), etc.
– Providing current information regarding available service providers and supporting members/legally responsible persons in choosing service providers, ensuring objectivity in the process
– Assisting members to direct the planning process/plan development, to the extent desired by the member
– Facilitating timely, accurate, and thorough development of high-quality Individual Support Plans and Positive Behavior Support guidelines (as applicable) per departmental standards.
– Actively collaborating with members supported and members of the treatment team to ensure development of a comprehensive plan that reflects the member’s needs and desired life goals. The individualized plan includes mitigation strategies for all identified health/safety risks and is compliant with all waiver requirements.
– Implement technical assistance strategies and utilize person-centered thinking tools and personal outcomes data to improve quality outcomes for members
– Promoting use of natural/community resources through the assessment/planning process.
– Ensuring that assessments/plans are updated, as needed, whenever the member’s life circumstances change
– Rounding and staffing cases with Supervisor, Clinical Consultation Team or Medical Team based on pre-determined triggers
– Performs tasks associated with monitoring and oversight to include:
– Monitoring case to ensure consistent implementation of plan, quality care, health/safety of the individual, as well as the continued appropriateness of services
– Ensuring that non-residential services are monitored (including direct observation of service delivery) in each setting that non-residential services are rendered
– Making announced/unannounced monitoring visits, including nights/weekends as applicable
– Monitoring services for compliance with state standards, waiver requirements, Medicaid regulations, as applicable
– Completing required plan implementation monitoring documentation and follow-up
– Assisting members with linkage to and coordination of medical care, as needed
– Assisting members with self-management plans
– Promoting problem-solving and goal-oriented partnership with members/legally responsible persons, providers, etc.
– Recognizing and reports critical incidents
– Promoting customer satisfaction through ongoing communication and timely follow-up on any concerns/issues, reporting all grievances and provider concerns in the appropriate database
– Performs tasks associated with documentation, fiscal accountability and risk management to include:
– Documenting clinical evaluation and impression of member needs and service recommendations, including clarification regarding a member’s preference for a specific service
– Educating members/families on methodology for budget development and mechanisms available to modify the individual budget
– Verifying that services are delivered as outlined in the person-centered plan and promptly addresses any deviations in service
– Ensuring that service orders/doctor’s orders are obtained, as applicable
– Verifying individual’s continuing eligibility for Medicaid with “PCHP” and “IN” Indicator (as applicable) and promptly follows-up on identified issues, as indicated
– Proactively responding to an individual’s planned movement outside the Cardinal Innovations geographic area to ensure changes in their Medicaid County of eligibility are addressed prior to any loss of service
– Coordinating Medicaid deductibles, as applicable, with the individual/legally responsible person and provider(s)
– Proactively monitoring own documentation to ensure that issues/errors are resolved immediately
– Ensuring accurate/timely submission of applicable service requests
– Ensuring all clinical documentation (e.g. outcomes, plans, progress notes, etc.) meet state, agency and Medicaid requirements and are submitted in accordance with identified timelines
– Ensuring security of protected health information (PHI) at all times following established procedures and protocols (e.g. transports PHI in trunk of car, uses red bag for transport, etc.)
– Provides assistance with obtaining and understanding need for adherence to medications
– Provides education to the family, member, and/or LRP regarding available community and crisis services
– Links members to population health management program upon discharge from care coordination services
– Consistently adheres to established Cardinal protocols and timelines
– Completes required notification to all supports as needed including but not limited to CCNC
– Ensures documentation of all interventions within required timelines
– Participates in clinical rounds/case consultations as indicated
– Engages with internal and external stakeholders in a professional manner and positively represents the Care Coordination department in all interactions
– This is a mobile position with work being done in a variety of locations. The I/DD Care Coordinator spends a considerable amount of time in the field and completes required documentation/paperwork at their home office or alternative locations with required. Driving is an essential function of the position. This position requires travel and may require additional hours beyond standard workday.


This job is performed with considerable independence and minimal daily instruction., with most work performed in the community, at home, and/or away from the office. Driving is an essential function of this role with a considerable amount of time in the community.

– Familiar with values and goals of Care Coordination and the 1915(b)(c) waiver
– High level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance
– Knowledge of clinical practice guidelines and the assessment and treatment of intellectual/developmental disabilities, with or without co-occurring mental illness
– Ability to learn and understand legal, waiver and program practices/requirements and to apply this knowledge in plan development, problem-solving and responding to questions/inquiries
– Exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts and established processes
– Negotiation and conflict resolution skills
– Positive, solution-focused approach to problem solving
– Attention to detail, with ability to organize tasks/priorities and complete with accuracy
– Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.)

Education and Experience:

– Master’s degree in a “Human Services” (Special Education, Psychology, Social Work) field with one year of full-time I/DD experience with the population served
– Bachelor’s degree in a Human Services field
– Bachelor’s degree in Child Development and Family Relations, Counseling and Guidance, Nursing, or Sociology with 2 years of full-time, professional I/DD experience with the population served.
– Completed twenty-five (25) hours of coursework in social work or counseling courses at an accredited four-year college or university. Coursework completed at a junior college, community college or technical institute will also be considered if credit for the course applied to the individual’s Bachelor’s degree. Must qualify as a QP for Developmental Disabilities.

Valid Driver’s License Required: Yes

Equal Opportunity Employer/ Protected Veteran/ Individuals with Disabilities

Cardinal Innovations is firmly committed to the policy of providing equal employment opportunity (EEO) to all of its employees and applicants for employment without regard to race, age, color, sex, religion, creed, veteran status, genetic information, national origin, non-job related disability, sexual orientation, and/or gender identity or expression (except as mandated by law). Employment at Cardinal is based solely on a person’s merit and qualifications directly related to professional competence. For that reason, we consider qualified applicants regardless of criminal histories, consistent with legal requirements. Our equal employment opportunity philosophy complies with federal, state and local law and applies to all aspects of employment with Cardinal, including recruiting, hiring, training, transfer/promotion, compensation, benefits and termination.

If you have a disability or special need that requires accommodation, please let us know by contacting Cardinal’s Human Resources department at Someone from the HR team will reach out to see how we may be able to assist.

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