CAMBA’s Health Homes 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.
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:
Maintain professional relationships with clients and client confidentiality.
Practice universal precautions.
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).
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.
May plan, coordinate and facilitate social/peer support events, including group facilitation for clients.
May prepare marketing materials for the program.
May input client data and client progress information into automated database.
May reach out and market the program to the community in order to recruit clients.
May prescreen clients over the telephone for eligibility and may schedule intake appointments.
May assist clients in completing applications for benefits and entitlements, and may process applications on clients’ behalf.
Tasks may be modified, expanded and/or assigned over a period of time.
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 – Spanish.
Some evening/weekend availability may be required.
How to apply
Please write “Case Manager II – Health Homes” in subject of e-mail.
Please send resume and cover letter in MS word attachment to: