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Care Coordinator, Health Home

​CAMBA's Health Home program is an innovative new model of care management focused on improving the health outcomes for individuals with severe mental illness & other complex chronic illnesses through coordinated networks of medical, psychiatric, behavioral health, social service & housing providers. Staff will use cutting-edge health information technology & a unified plan of care to ensure all clients connect to & maintain primary medical care, prevent hospital stays, &/or reduce the length of hospitalizations. CAMBA's participation in health home places it at the forefront of a broad system wide change that will have a significant impact on many human services sectors.

 

Essential Duties and Responsibilities:  The person filling this position is expected, under general direction, to: (1) aid individuals and/or families requiring social service assistance; (2) interview and evaluate applicants for services, formulate service plans and goals, and aid clients to implement service plans; (3) locate and make use of appropriate community resources for clients; (4) evaluate actual living conditions of clients though home visits; including the following:  ​

  • Comply with any and all Federal, State, City and CAMBA security and privacy polices intended to protect the security and privacy of individually identifiable health information.
  • Review all documentation establishing clients' eligibility for program and make file copies (e.g. Medicaid status and confirmation of HIV status).
  • Assist clients in completing all CAMBA intake applications and forms.
  • Create and maintain client files.
  • Conduct initial intake or assessment of clients and clients' families and/or periodic reassessments.
  • Conduct case conferences prior to finalizing all assessments / reassessments.
  • Follow-up with clients and with referral organizations regarding client contact and progress with referral organization.
  • Work with clients to break through barriers to client goals and to assist clients in advocating for themselves and in moving toward self-sufficiency.
  • Recommend and implement strategies to persuade clients to participate more fully in this process.
  • Monitor clients' progress toward their service plans goals via regularly scheduled telephone contact and/or face-to-face home and office visits, and document via service plan outcomes and detailed progress notes (i.e. time of service, type of service, etc.).
  • Recommend closing of cases in which clients have: (a) achieved primary goals and have maintained stability for a period of months; or, (b) have not demonstrated a willingness to participate in the process (lost-to-service); or, (c) have become ineligible for services (e.g. moved out of area, change in Medicaid status).
  • Provide all required information for weekly/monthly/quarterly/annual reports (e.g. # of clients in managed care programs, # of clients housed, etc).
  • Act as client liaison/client advocate with outside organizations regarding such matters as education, healthcare, housing, legal issues, entitlements, etc.
  • Escort clients to appointments (educational, medical, social service, etc.)
  • Follow-up with clients for a period of time after successful completion of their primary goals to assure client stability.
  • Tasks may be modified, expanded and/or assigned over a period of time.

Minimum Education/Experience Required:

  • Bachelor's degree (B.A. or B.S.W) and two years of applicable experience and/or equivalent experience.

Other Requirements:

  • Knowledge about, understanding of, and ability to work closely with, persons with HIV/AIDS and related issues. Bi-lingual English with any one of the following languages: Spanish, Russian, Haitian-Creole, Chinese (Mandarin or Mandarin/Cantonese) preferred.
  • Some evening/weekend availability may be required. 

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