Care Coordinator (RISE, Spanish/English) https://bhchpjobs.applytojob.com/apply/niVGxu9zZE/Care-Coordinator-RISE-SpanishEnglish Job Summary: Hours: Monday-Friday, 8:30 AM- 5:00 PM The Care Coordinator will be an integral part of a multidisciplinary team within our RISE (Reentry Initiatives for Support and Empowerment) program working with homeless, incarcerated individuals in Suffolk County. BHCHP has partnered with the Suffolk County Sheriff?s Department (SCSD) at two county jails to outreach to this population. This program aims to engage this population prior to release, to connect with external Medication for Opioid Use Disorder (MOUD) partners to improve transitions of care for these individuals upon release, and ultimately to improve outcomes related to drug use in this population who are at a particularly high-risk of fatal overdose upon release. The Care Coordinator will join an interdisciplinary team of doctors, nurses, a clinic/project director, therapist, care coordinators, recovery coach and others working together to support incarcerated individuals with a diagnosis of opioid use disorder and those at high risk of fatal overdose prior to release, on the day of release, and in the post-release period to provide the following: Pre-release support including Critical Time Intervention, case management, behavioral health services, psychiatry, recovery support groups, legal case management, MOUD evaluations, HIV and HCV screening and referrals, and recovery coaching. Services are provided directly in in-person at the jail when permitted, or by telehealth encounters. Support on day of release from jail including in person visits to the jail or courthouse, transportation support, care coordination, accompanying individuals to medical appointments and to obtain prescriptions, naloxone provision and naloxone training for overdose reversal. Post-release support including a continuation of pre-release supports, as well as support with direct MAT provision, psychiatric treatment/medication bridging, individual therapy, and Hepatitis C (HCV) treatment. BHCHP utilizes a harm reduction model to recovery and the care coordinator will be working with individuals at all stages of recovery. This position offers a tremendous opportunity to work at the intersections of the opioid epidemic, incarceration, and homelessness, to address the root causes of illness in a collaborative team-based community health center context. Applicants must be proficient in both English and Spanish. Responsibilities: Meet with patients in jails to assess patients? financial, housing, legal, addiction treatment, and other social service needs in the pre-release period. Develop comprehensive patient centered care coordination plans to address these needs and provide support and follow up in the post-release period; Work with program participants to ensure they are effectively bridged to community-based OUD treatment post-release, including mitigating lapses in care associated with waiting lists and other barriers. Obtain program participants? consent to communicate with community-based OUD treatment providers, in accordance with HIPAA and 42 CFR; obtain informed consent to participate in the program evaluation and assist with data collection at baseline and 6-month time points; In partnership with SCSD staff, provide care coordination services to enroll or facilitate re-enrollment in insurance coverage for all program participants prior to or immediately after their scheduled release from SCSD, to ensure there are no gaps in coverage that would otherwise preclude individuals from continuing MOUD post-release. Provide care coordination to support reentry, identify community resources, and connect participants to medical and social services post-release (such as transportation, primary care, naloxone, and housing); Support BHCHP?s Correctional Linkage to care grant by screening individuals for interest n HCV treatment and activ