The HH+ Care Coordinator functions as a member of an interdisciplinary team to provide care coordination to a caseload of severely mentally ill adults with multiple medical co morbidities and/or co-occurring substance abuse disorders. HH+ Care Coordinators advocate for and support the client, engage with community agencies/health care providers and others on his/her behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations. + Conduct appropriate screening and either performing or arranging for more detailed assessments when needed (e.g., high-risk substance use or mental health related indicators, harm to self/others, abuse/neglect and domestic violence). + Navigating the mental health service system-including ability to make referrals to mental health housing services, crisis intervention/ diversion, peer support services + Collaborates with inpatient staff and MCO (as applicable) to affect successful transitions out of inpatient or institutional settings + Conduct hospital visits for clients admitted for inpatient psychiatric treatment + Share and collaborate discharge summaries with outpatient care teams + Addressing the quality, adequacy and continuity of services to ensure appropriate support for individuals' mental health and psychosocial needs. + Maintain engagement with individuals who are often disengaged from care, have difficulty adhering to treatment recommendations, or have a history of homelessness + Develop service plans and resolve barriers to effective service utilization. + Accompany clients to/from any appointments when needed. + Document service information in databases and use electronic systems to track participant activities. + Assist in crisis intervention and provide or refer to crisis services. + Extensive field work required, including home visits and community work such as visiting hospitals and emergency rooms when determined necessary. + Assist with applications for entitlements such as (but not limited to): SNAP, SSI/SSD, HEAP + Ensure that clients follow-up with aftercare discharge (i.e. fill prescriptions, make appointments). Skills and/or Experience Required: + For B.A. level candidates, two (2) years OR for M.A. level candidates, one (1) year of related experience working with individuals with severe mental illness. + Ability and willingness to regularly travel, in some instances with clients in Agency vehicles to many locations using various modes of reliable and safe transportation + You must have excellent interpersonal and time management skills. + Proficiency in email and documentation on electronic platforms. + Comfortable with fieldwork and navigating social services systems. Preferred: + Knowledge of Medicaid, Social Security and other entitlements + Bilingual /Spanish a plus + Bilingual /Creole a plus Benefits + Competitive Salary + Medical/Dental + 401k (with company match) + Profit Sharing + Employee Referral Program + Supplemental Benefits + Paid Time off + Holidays