Care Coordinator for Harm Reduction

We are seeking a Care Coordination for Harm Reduction to join our dynamic Care Coordination Team!

Job purpose

The Care Coordinator for Harm Reduction coordinates client intakes and non-clinical services at Fair Haven Community Health Care’s (FHCHC’s) shelter- and street-based services. The Care Coordinator addresses the social and structural factors at play for clients in the in a manner that is consistent with FHCHC’s policies and mission. Upholding the principles of harm reduction, the case manager will use a recovery-oriented approach to all individuals seeking services.

Duties and responsibilities

Reporting to the Harm Reduction Lead, the Care Coordinator for Harm Reduction will screen for social determinants of health at least yearly using a validated screening instrument on all clients. Typical duties include but are not limited to:

• Liaison with other organizations and care providers, including city and state agencies, to link clients to available and appropriate services
• Develop and evaluate shared plans of care
• Link patients with social needs to community resources
• Assist with and follow-up on the successful completion of health maintenance items (e.g. lab testing, annual visits) and chronic disease management (e.g. routine diabetic or asthmatic care)
• Conduct home visits as needed
• Identify barriers to care impacting clients’ abilities to adhere to treatments
• Work collaboratively with clinical teams to meet the clinical and social needs of high-needs, high-cost patients
• Attend relevant trainings as required and assigned
• Document client referrals, encounters, and services in the EPIC electronic health record and communicate securely with other team members and clinicians
• Maintain strict adherence to all deadlines including report deadlines and timely completeness of documentation
• Coordinate food, laundry, and shower services for clients at shelter-based services