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Care Coordinator, Health Homes

Who We Are: CAMBA is a community of staff, volunteers, clients, donors, neighbors and partners who work together to build an inclusive New York City, where all children and adults have access to the resources and supports they need to thrive.  We take a comprehensive approach by offering more than 160 integrated programs in:  Education & Youth Development, Family Support, Job Training & Employment Support Services, Health, Housing, and Legal Services. We reach more than 65,000 individuals and families each year at our 90 locations, including 20,000 youth.  CAMBA serves a diverse cross section of New Yorkers from new mothers in Brownsville to job seekers in the Rockaways. More than half of our clients are immigrants and refugees from around the globe. Over 85% of our families are in living in poverty, reflecting the challenges faced by nearly 1.7 million New Yorkers today.

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.

Responsibilities: 

  • 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.

Requirements:

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

EOE:
CAMBA is an Equal Opportunity Employer. We value a diverse workforce and inclusive workplace. People of color, people with disabilities, and lesbian, gay, bisexual, and transgender people are encouraged to apply. We consider all applicants without regard to race, color, religion, creed, gender, gender identity, gender expression, national origin, age, disability, socio-economic status, marital or veteran status, pregnancy status or sexual orientation.​​



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