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Care Coordinator II (HARP), 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. 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.

The HARP (Health and Recovery Plans) Care Coordinator position is an exciting opportunity to be a part of the implementation of an important new state initiative designed to improve the lives of New Yorkers living with Chronic Mental Illness or Substance Use Disorder. The Project Coordinator is responsible for linking all eligible clients to community-based services designed to enhance their lives. 


The Care Coordinator is Expected to:

  • Maintain professional relationships with clients and client confidentiality.
  • Practice Universal Precautions/Standard Protocol & Procedures.
  • 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.
  • Complete the Initial Eligibility and Full NYS Community Mental Health Assessments (CMHA) on clients that are enrolled in HARPs (Health and Recovery Plans) in order to determine eligibility for Home and Community Based Services (HCBS).
  • Create and update as necessary a Plan of Care (POC) in conjunction with the client in the appropriate Health Homes database for clients that are eligible for HCBS.
  • Regularly communicate with Managed Care Organizations (MCOs) regarding the Plan of Care and approval of services.
  • Input client data and client progress information into automated database.
  • Schedule intake appointments between the eligible individuals and the care management team as needed.
  • Review all documentation establishing clients' eligibility for program and make file copies (e.g. Medicaid status and confirmation of HIV status).
  • 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.)
  • Case Conference with all providers involved with the patient's care; care settings which include inpatient settings, actively participates in discharge planning and care transitions assisting in the reintegration of the individual into the community.
  • Arranges contact with patient upon discharge from inpatient services or ER.
  • Follow-up with clients and with referral organizations regarding client contact and progress with referral organization.
  • Assist eligible individuals with completing all CAMBA and Health Home enrollment and consent forms.
  • Conduct initial needs assessments and assessment of eligibility for clients and clients' families.
  • Evaluate actual living conditions of clients through home visits.
  • Work with clients to break through barriers to their goals and to assist them in advocating for themselves and move toward self-sufficiency.
  • Monitor clients' progress towards their service goals, and document all interactions with clients via progress notes.
  • Create and maintain client files and make copies of all client documents.
  • Provide all required information for weekly/monthly/quarterly/annual reports (i.e. client services reports, documentation ticker/ tracking reports, client contact reports, vehicle incident reports).
  • Represent CAMBA at community meetings and forums. 
  • Research and assess client and community needs to keep services and offerings current and relevant.
  • Recommend and implement strategies to persuade clients to participate more fully in care plan.
  • Prepare periodic written assessments and document clients' progress.
  • Refer clients to other CAMBA services to assist clients in eliminating barriers to success.
  • 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).
  • Follow-up with clients for a period of time after successful completion of their primary goals to assure client stability.

 

EDUCATION/EXPERIENCE REQUIRED (as per funder):

  • Bachelor's Degree (B.A.) in any of the following: child & family studies, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreation therapy, rehabilitation, social work, sociology, or speech and hearing; OR A Bachelor's level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses; OR NYS licensure and current registration as a Registered Nurse and a bachelor's degree; OR A Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and 2 years of applicable experience; 
  • Experience providing direct services and linking persons to a broad range of services essential to successfully living ​

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