Senior 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 180integrated programs in:
Education & Youth Development, Family Support, Job Training & Employment Support Services, Health, Housing, and Legal Services. We reach more than 72,000individuals and families each year at our 100locations, 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 live in poverty, reflecting the challenges faced by nearly 1.7 million New Yorkers today.

CAMBA’sHealth Homeprogram 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 and a unified plan of care to ensure all clients connect to and maintain primary medical care, prevent hospital stays, and/or reduce the length of hospitalizations.

CAMBA's participation in health homes places it at the forefront of a broad system-wide change that will have a significant impact on many human services sectors.

Position:
Senior Care Coordinator

Reports To:
Supervisor

Location: 2244 Church Ave Brooklyn, NY

The person filling this position is expected, under general supervision, to: (1) aid individuals and/or families requiring social service assistance;(2) 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.(3) Locate and make use of appropriate community resources for clients; (4)
Practice Universal Precautions/Standard Protocol & Procedures (5)
Evaluate actual living conditions of clients though home visits.

• Maintain professional relationships with clients and client confidentiality.
• 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.
• Manage a caseload of approximately 55 clients.
• Conduct initial intake or assessment of clients and clients' families and/or periodic reassessments.
• Interview and assess applicants for services, develop service plans and goals, and support clients in implementing those plans.
• Conduct case conferences prior to finalizing all assessments / reassessments.
• Follow up with clients and referral organizations regarding client contact and progress with referral organization.
• Work with clients to break through barriers to client goals and to assist clients inadvocatingthemselves 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,…