Adult Family Care Coordinator -(Bilingual preferred) Gardner

Employment Type

: Full-Time


: Healthcare - Allied Health

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Adult Family Care Coordinator -(Bilingual preferred) Gardner


Job ID: 2019-5537
Type: Regular Full-Time
# of Openings: 1
Category: Management
AFC North


Open Sky Community Services is a human service agency that provides counseling services and treatment options to people diagnosed with a mental illness or developmental disability.The AFC Program provides assistance to families who share a home with a qualifying person with a disability. The AFC Coordinator assists the person and family to research/obtain/maintain entitlements, conducts assessments, and assists with identifying new resources like respite. The AFC Coordinator acts as a liaison between the person served, the family, funder, and other members of the team including clinical providers. This is a full time position and is predominantly first shift Monday-Friday. Due to the nature of the position, it is necessary that AFC Coordinators be available for in home visits in the evenings. AFC Coordinators rotate an emergency pager and must be available to field phone calls and offer support around the clock during their time when on pager (usually one week per month).


  1. Monitor, support, train and evaluate AFC caregiver and member.
  2. Assist in the development of meaningful community roles and relationships.
  3. Coordinate with multidisciplinary team, caregiver and member to develop the member’s interim and final AFC plan of care.
  4. Ensure implementation of the AFC plan of care during scheduled home visits.
  5. Conduct on-site home visits with the AFC caregiver and member monthly for Level 2 and every other month for Level 1 alternating with the AFC RN and/or more frequently as needed.
  6. Identify and develop clinical supports using consultants as needed.
  7. Assist member and caregiver with making referrals to other service providers as needed.
  8. Coordinate and work with other services the member is receiving or in need of such as Mass Health, managed care organizations, accountable care organizations and/or other agencies such as visiting nurse services, therapy services, DDS services, DMH services, MRC, and other services as needed.
  9. Maintain all required records and documentation.
  10. Complete a progress note corresponding with each on-site visit or encounter and/or more often as needed.
  11. Work with and report any changes to the members condition to the members AFC RN.
  12. Conduct regular evaluations, at least annually, to ensure that the qualified setting where the member receives AFC continues to meet the requirements.
  13. Provide timely assistance and respond to urgent or emergency needs of the member and caregiver.
  14. Develop with the multi-disiplinary team the caregiver and member an emergency back-up and personal care contingency plan for each member, including an alternative plan for the member if AFC caregiver is unable to provide care.
  15. Participate in the AFC on call rotation and provide crisis intervention, as necessary.
  16. Establish and maintain ongoing contact with individual’s family, guardians, and significant others.
  17. Perform other duties as assigned.


BA in human service field plus 2 years relevant experience. Residential and administrative experience preferred. Relevant training and experience may be considered in place of a degree. High School diploma/GED and valid Driver’s License is required.


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