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Case Manager II, Transitional Care Coordination

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 10,000 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 Transitional Care Coordination (TCC) program will link 60 individuals to housing and primary medical care.  Program staff members along with each client will develop a coordinated service plan that will ensure that the client is connected to a wide range of services including, but not limited to, medical, mental health, housing, and substance abuse treatment services and has access to public benefits and other supportive services.  When necessary, staff will also accompany clients to medical and other appointments to ensure that their medical and other needs (e.g. housing) are being met.  On at least five occasions, staff will conduct one-on-one health promotion counseling sessions with each client, which will follow modules from DOHMH required curricula, such as Prevention for Positives, Me and HIV, What is HIV and how does it affect my body, Identifying and Building Social Support Networks, and Medical Appointments and Providers.  Once clients are connected to housing and medical care, program staff will facilitate the transfer of their cases to a Ryan White Care Coordination program, a COBRA program or another case management program.  Finally, staff will follow-up with clients after their transfers to ensure that the transitions have been smooth and positive.   


  • 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 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).
  • Evaluate actual living conditions of clients through home visit.
  • 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.


  • Bachelor's degree (B.A., B.S.) and two years of applicable experience and/or equivalent experience.
  • Bilingual preferred.
  • Strong socio-cultural identification with the target population​
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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