Service Coordinator - TBI Waiver Program
Job Details
Schofield Certified Home Care - Kenmore, NY

The Service Coordinator (SC) provides case management to participants and prospective participants of the Home and Community Based Service/Traumatic Brain Injury Waiver Program of New York State (HCBS/TBI Waiver).  The SC coordinates and monitors all of the services in the participant’s Service Plan, which may include Medicaid State Plan Services, as well as educational, vocational, social and medical services.  The SC works with the participant to increase their independence, productivity and integration into the community while maintaining their health and welfare.

 The maximum number of HCBS/TBI Waiver participants that can be served by a Service Coordinator is seventeen (17).

 A Service Coordinator is prohibited from providing any other HCBS/TBI Waiver service to any waiver participant for whom he/she is providing service coordination.


A.  Education and Training -  In order to quality to provide service coordination to TBI waiver participants, one of five combinations of education/training/experience must be held:

  1. Person with a Master of Social Work;
    Certified Rehabilitation Counselor;
    Registered Occupational Therapist;
    Registered Physical Therapist;
    Registered Speech-Language Pathologist;
    Registered Professional Nurse;
    Person with a Master or Doctorate in Psychology; or
    Certified Special Education Teacher
    These providers shall have, at a minimum, one year experience providing service coordination and information, linkages and referrals regarding community based services for individuals with disabilities.
  2. An individual with a BA degree with two (2) years’ experience providing service coordination and information, linkages and referrals regarding community-based services for individuals with disabilities;
  3. Be an individual with an Associate’s Degree and three (3) years’ experience providing service coordination and information, linkages and referrals regarding community-based services for individuals with disability;
  4. Be an individual with a High School Diploma, or equivalent (GED) with four (4) years’ experience providing service coordination and information, linkages and referrals regarding community-based services for individuals with disability;
  5. Be an individual who has successfully served as a Regional Resource Development Specialist.

Individuals identified in Section (A) may supervise the following individuals to perform Service Coordination Services: 

  • Individuals with educational experience listed in (1) but who do not meet the experience qualification. 
  • Individuals with a Bachelor’s Degree in health or human services with one (1) year of experience providing Service Coordination for individuals with disabilities and knowledge about community resources. 
  • Individuals with an Associate’s Degree or a High School Diploma or GED and two (2) years of experience provide Service Coordination to individuals with disabilities and knowledge about community resources.

B. Character – The individual must possess good moral character, patience and compassion for the chronically ill or disabled.

C. Must possess a valid driver’s license and have a car available for use.

Essential Job Functions 

  1. Read, write speak, hear, reason and remember. 
  2. Stoop, kneel, crouch, reach, stand, walk, push, pull, and lift light weight (1-24 lbs.). 
  3. To perform all job duties and responsibilities as outlined below in IV.

Job Duties and Responsibilities
The Service Coordinator is supervised by the Director, or Assistant Director, of the Long Term Home Health Care Program.  The job duties and responsibilities are to be performed while observing the following standards:  job knowledge, job ability, job skills, technical skills, quality, quantity, judgment/problem solving, decision making, creativity, and initiative.  The responsibilities include but are not limited to: 

  1. Formally reviewing, updating and submitting timely Service Plans (Initial Service Plans, Revised Service Plans and addendums) to RRDS for review and approval.  Assure that Service Plan is appropriately administered. 
  2. Organizing and facilitating Team Meetings for each participant, at a minimum, every six (6) months when a revised Service Plan is developed. 
  3. Assuring that the PRI/Screen is completed at least every twelve (12) months or whenever the participant experiences a significant improvement in his/her ability to function independently in the community. 
  4. Maintaining records of waiver transportation as described in the TBI Manual section on Transportation Services. 
  5. Assuring that all waiver service providers and the participant receive a current copy of the most recently approved Service Plan.
  6. Maintaining knowledge of all approved waiver service providers in their region.
  7. Conducting face to face participant visits at least monthly.  A monthly visit must be in the participant’s home no less than once per quarter.
  8. Acting as a neutral advocate in assisting the participant with the selection of waiver service providers.
  9. Identifying any impediments to achieving projected milestones and addressing any issues affecting the participant.
  10. Participating in TBI Waiver meetings and educational offerings by the local RRDS and/or Department of Health.
  11. Investigating and following up on all recordable and serious reportable incidents.  Assuring that this information is communicated to the RRDS as indicated in the NYS Department of Health HCBS/TBI Waiver Manual.
  12. Assuring adequate coordination, effective communication and maximum cooperation between all sources of support and services for the participant.
  13. Documenting service coordination visits and contacts made with participants or providers in facilitating implementation of Service Plan. Submitting accurate visit notes to support billing. 
  14. Participating in Annual TBI Training provided by Schofield.
  15. Performs other related duties as required by their manager.

 General Duties and Responsibilities
A.    Participate in department meetings, mandated inservices, and assigned committees. 
B.    Maintain a positive and professional relationship with participant, family members, informal/formal supports, and other service providers. 
C.    Maintain a positive and professional relationship with all personnel, including supervisors, co-workers and volunteers. 
D.    Follow all safety regulations and precautions at all times; use protective devices as required. 
E.    Wear and maintain proper clothing as established in the uniform dress code policy, including name tag identification.  Maintain acceptable personal hygiene. 
F.     Maintain confidentiality and participant’s rights.

G. Maintain confidentiality of all issues and subject matters, including records, reports, data and other related sensitive materials.
H.    Maintain an acceptable attendance rate.
I.     Follow all laws, rules and regulations of the Federal and NYS Health Codes in regard to the department and overall organization operations.

Working Environment
The Service Coordinator is subject to outside environmental conditions as well as conditions found in participant’s home.  The normal hours of work are 8:00 a.m. to 4:00 p.m.  Overtime hours may be encountered.

Exposure to Blood and Airborne Pathogens
This position has been categorized into Occupational Safety and Health Administration (OSHA) Category 1 – routine contact with blood/body fluids of persons living or non-living.  Contact can be made while handling regulated medical waste in clean up of spills and other blood/body fluid accidents.  Protective equipment should be utilized when performing these tasks.
This job description, in no way, states or implies that these are the only duties to be performed by the employee occupying this position.  Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by their supervisor.
Qualifications, essential job functions and requirements are representative of minimum levels of knowledge, skills and/or abilities.  To perform this job successfully, the incumbent will possess the abilities or aptitudes to perform each duty proficiently.

This document does not create an employment contract, implied, or otherwise, other than an "at will" employment relationship.

I attest that I have read and understand this job description.  I also understand that I am responsible to carry out the duties described in this job description.