VNA Health Group

NJ InCK Advance Care Management Team(ACMT) Coordinator

Job Locations US-NJ-Ocean County
Posted Date 1 month ago(4/24/2023 5:11 PM)
# of Openings
Regular Full-Time
Administrative/Clerical/Clinical Support


Spanish Language Community Health Worker, InCK Program 

"A Caring Coach Helping Families Meet Their Goals in Well-Being."



Why the Children and Family Health Institute for you?


As a VNAHG employee, you’ll not only be joining a winning organization, but one that will help you achieve your personal and professional goals.

  • Our tuition reimbursement program of up to $12,000 a year will assist you getting that degree you’ve always dreamed of.
  • Our Continuing Education programs will keep you current, with learning and certifications to help you master your profession.
  • Our online learning system will provide knowledge at your fingertips, any time, anywhere.
  • Our Employee Referral programs give you the opportunity to recruit trusted colleagues and receive cash rewards for doing so.
  • Our recognition programs provide that much needed “thank you” for doing a job well done.
  • Our 403B and 401A retirement plans will help you plan for your future.
  • Our leadership fosters a culture of support, while giving you the freedom to bring your best self to work every day.

The VNA Health Group. Moving health care – and your career – forward, since 1912.


The Children and Family Health Institute of the VNA Health Group provides a multitude of community health services. From pediatric home care and early intervention programs to prenatal care, primary care, and dental health, the Children and Family Health Institute at Visiting Nurse Association Health Group supports people of all ages with more than 20 programs and services. We strive for every child and family in New Jersey to be happy and healthy by linking vital community resources to those who need them.

Each year, more than 54,000 parents and children rely on the Children and Family Health Institute to access the care and services they need to achieve their best level of health and well-being.





  • Oversees the Advanced Care Management Team (ACMT).
  • ACMT includes the LSW, community health workers (CHW), a Family Support Specialist (FSS), and a Certified Child Life Specialist (CCLS).
  • Each ACMT will be responsible for a group of families with children and youth (0-20) enrolled in the NJ-InCK program and screened to be at high risk. These children have complex/chronic health complexity, a combination of behavioral, social, and medical complexity that put them at risk for increased utilization of emergency department care, inpatient admissions, and being placed outside the home.
  • The ACMT will draw on a strong network of NJ InCK partners and use new technology for communicating and making referrals. The team will ensure the children/youth are connected to appropriate Core Child Services including physical and behavioral health care, childcare and preschool, school delivered services, food and housing supports, and  legal services.
  • The LSW oversees the ACMT and directly supervises each member of the multi-disciplinary team.
  • They will review Intake and the assignment of caseload to the members of the ACMT, coordination and participation of the ACMT as part of interdisciplinary plan of care conferences, and be responsible for communications and participation with the NJ-InCK Care Coordination program, including regular reporting and maximizing use of the data and communications systems which will form the core of both day-to-day ACMT functioning and program improvement and evaluation. 


Principal Responsibilities:


  • Supports organization’s mission by striving for excellence in all aspects of their job with a focus on positive interpersonal relationship with co-workers.
  • Oversees the Advanced Care Management Teams (ACMT), directly supervising the Community Health Workers,  Family Support Specialist, and a Certified Child Life Specialist
  • Provides reflective supervision, as well as direct job task supervision to all team members.
  • Establishes and maintains effective and collaborative relationships with the medical/behavioral health providers and community-based services in the Team’s assigned region of Monmouth and/or Ocean County.
  • Assists and provides all team members with any needs identified for coordination of clinical or community resources for a child/youth under the team’s care.
  • As needed, serves as back-up liaison between beneficiary/family and ACMT to ensure the beneficiary is receiving the services they need from each team member.
  • Through internal Team-based case conferences and chart review, reassesses effectiveness of interventions and develops new approaches to effective creation of the individual child’s Care Plan and supporting their progress on chosen goals and care pathways.
  • Sets-Up the beneficiary interdisciplinary care conferences in conjunction with the Care Integration Manager.
  • Reports to and engages in regular supervision with Dir. Center Early Childhood
  • Ensures Team provides culturally and linguistically appropriate services.
  • Advocates for Individuals and Communities.
  • Participates in formal ongoing program improvement activities of the NJ InCK Model.
  • Tracks performance and outcomes, including using dashboards and ensuring these are produced and analyzed on an ongoing basis.
  • Provides data driven information to the InCK Core Team
  • Adheres to VNAHG policies, including those for infection control, trauma informed resilience oriented care and safety


Job Competencies & Minimum Qualifications:

  • Experience: 3+ years of professional work related to the care of children and /or youth, prior care coordination and management experience. Prior program development experience a plus.
  • Advanced computer proficiency including ability to use new Care Coordination systems as well as Microsoft Office including advanced Excel; Project management and dashboard documentation and analysis skills highly recommended.
  • Excellent verbal, written and interpersonal communication skills,  bilingual preferred
  • Strong organizational and team management skills


Working Conditions/Physical Demand:  Working indoors at VNA locations and with travel to community locations to meet families/youth and providers of Core Child Services.  Occasional participation in community events that may be held out of doors.


This job description is intended to convey information essential to understanding the scope of the Access Center Specialist's position and it is not intended to be an exhaustive list of experience, skills, efforts, duties, responsibilities, or working conditions associated with the position.


VNA Health Group provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.


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