Medical Respite Case Manager

The Medical Respite Case Manager is responsible for coordinating care and providing support to patients discharged from hospital settings into the Medical Respite Program. The Case Manager ensures that individuals adhere to medical and behavioral health follow up care, develop independent living skills, and successfully transition to permanent or stable housing.

The role includes developing individualized Service Plans, facilitating linkage to internal and external providers, supporting patients with activities of daily living when needed, and collaborating closely with multidisciplinary partners, including medical providers, Housing Navigators, and program staff to promote recovery, wellness, and housing stability.

Essential Duties:

Care Coordination & Service Planning

• Conduct comprehensive biopsychosocial assessments and identify medical, behavioral health, substance use, and social service needs.
• Develop, implement, and monitor individualized Service Plans based on patient goals.
• Coordinate referrals to internal support, primary care, behavioral health, specialty services, and community providers.
• Provide short term counseling, motivational support, and psychoeducation on recovery, health literacy, and treatment adherence.
• Serve as the primary liaison between patients, providers, hospitals, and community partners.

Patient Support & Independent Living Skills

• Support patients in building self care routines, medication adherence, and health management skills.
• Assist patients with daily living tasks when required (e.g., mobility support, meal assistance, hygiene prompting).
• Escort patients to medical or social service appointments as needed.
• Promote skill development in budgeting, household management, and community reintegration.

Documentation & Compliance

• Maintain complete, accurate, and timely documentation within electronic medical records.
• Prepare narrative summaries, incident reports, and required statistical reports.
• Ensure that all documentation meets program, agency, and regulatory standards.
• Participate in quality improvement activities, audits, and program evaluation processes.

Discharge Planning & Housing Support

• Collaborate with Housing Navigators to support patients in meeting their Housing Agreement and discharge goals.
• Assist in developing discharge plans, including aftercare appointments, community referrals, and follow up care needs.
• Provide support for up to 90 days’ post discharge when applicable.

Program Operations & Safety

• Contribute to maintaining a safe, therapeutic, and supportive environment.
• Participate in crisis intervention and emergency responses.
• Follow all agency policies and utilize personal protective equipment as required.
• When shift coverage issues arise, remain on duty until appropriate replacement staff are secured.

EDUCATION & EXPERIENCE

• Associate degree required (Bachelor’s preferred).
• High School Diploma with 5 plus years of relevant experience with working with people living with substance use, chronic medical conditions and homelessness may be considered.
• CPR, First Aid, and Crisis Prevention certifications (or obtained shortly after hire).
• Minimum one year of experience in residential, community based, or medical respite settings.
• Experience working with individuals with disabilities, mental illness, or complex health needs.
• Knowledge of basic medical tasks, vital signs monitoring, and NYS Home Care guidelines preferred.