Transitional Living Services of Northern New York


Transitional Living Services
of Northern New York

Administrative Office
482 Black River Parkway
Watertown, NY 13601

Behavioral Health and Wellness Center
7550 South State Street
Lowville, NY 13367

110 Ogden Street
Ogdensburg, NY 13669


Maximizing Independence through Wellness

Individualized Care Coordinator (ICC)

  • Job Tracking ID: 512424-619148
  • Job Location: Ogdensburg, NY
  • Job Level: Mid Career (2+ years)
  • Level of Education: BA/BS
  • Job Type: Full-Time/Regular
  • Date Updated: May 03, 2018
  • Years of Experience: Less Than 1 Year
  • Starting Date: ASAP

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Job Description:

SUMMARY: The Individualized Care Coordinator (ICC) is responsible for engaging the child and family in a partnership of shared decision-making and service plan implementation throughout their enrollment in the HCBS Waiver. The ICC ensures and coordinates a comprehensive set of supports, resources and strategies for each child and family. The ICC works closely with outpatient clinics, day treatment programs and other providers to assure that Waiver services and clinical treatment modalities augment each other for optimal outcomes for children and families. This position may require use of personal vehicle to transport clients when an agency vehicle is not available.


Engagement of child and family throughout Waiver enrollment;

Intake and screening - the process of reviewing the referral packet from SPOA;

Initial assessment of strengths and needs - the preliminary process of assessing a child and family’s strengths and needs as a precursor to service plan development;

On-going assessment and documentation of the child and family’s strengths and needs, progress towards achieving goals, and efficacy of delivered services;

Completion of the Child and Adolescent Needs and Strengths (CANS), at start-up (if not completed by SPOA), 30 days after enrollment, every 180 days thereafter, at discharge and as needed;

On-going consultation with: treatment providers to reciprocally inform both clinical treatment and Waiver strategies, physical health care providers, schools and other relevant collateral sources, Respite, Skill Building, Family Support, and others (e.g., paid through flex dollars) who are involved in implementing the service plan.

Development and updating of services plans in partnership with the child and family that are: reflective of the child and family’s priorities, individualized, strength-based, and related to all life domains, culturally sensitive and relevant, complimentary with any psychiatric treatment received through other providers, focused on developmental tasks, resiliency and wellness, inclusive of safety issues, targeted to address assessment indicators (e.g., CANS), and oriented towards discharge readiness;


Oversight of all documentation in the case record;

Development and updating of a Safety Alert Plan with the child and family in collaboration with the treatment provider;

Coordination and monitoring of Waiver service delivery;

Discharge and after-care planning;

Linkage and referral to services and supports as specified in the service plan;

Identifying local resources and services for use during both enrollment and discharge planning,

Sharing information with the child and family concerning relevant resources and service providers, including local family support programs, advisors and advocates,

Advocacy which includes: the process of helping to empower children and families to initiate and sustain interactions that support their overall wellness, interceding on their behalf when necessary to gain access to needed services and supports;

Maintenance of the approved HCBS Waiver budget designated for each child. The ICC is responsible for compliance with Waiver fiscal and program guidelines through all phases of the child’s enrollment.

Provides Intensive-In-Home services that include: on-going activities in the home or community designed to avoid crisis situations; this may include psycho-education, crisis de-escalation strategies, parent-child relationship building, and the improvement of parenting skills.

Provides crisis response services designed to stabilize children and families when they are in crisis; this includes assessment, consultation and immediate interventions wherever and whenever necessary, and linkages to other appropriate services; provides 24 hrs/day on-call supports when scheduled.


Conducts a minimum of six visits monthly relative to each child of which three must be face-to-face, and the other three can be with collaterals.


Maintain agency policies and procedures in all program areas.


Maintains client confidentiality at all times and performs any related duties.


Attends appropriate training and in-service seminars in accordance with agency requirements.


Other job related duties as assigned.

Experience and Skills:


Master’s degree in one of the following fields: audiology, child and family studies, communication disorders, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreation therapy, rehabilitation, social work, sociology, or speech and language pathology, human services, human development, criminal

justice or other related degrees, or a NYS Teacher’s Certificate, and one (1) year experience providing direct services for children with one or more of the following primary diagnoses:

mental illness, mental retardation, alcoholism, chemical dependency or substance abuse, or a Bachelor’s degree in one of the above fields, or a NYS Teacher’s Certificate, and two(2) years experience providing direct services, or providing linkage to services, for children with one or more of the following primary diagnoses: mental illness, mental retardation, alcoholism, chemical dependency or substance abuse. *Qualifying experience may be pre- or post- degree. Candidates may qualify by meeting the qualifications for the NYS Intensive Case Manager position.

Office: (315) 782-1777

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