Job Summary: The Care Manager is responsible for providing comprehensive care coordination and support services to individuals experiencing homelessness. They work closely with program members to assess their needs, develop individualized service plans, and connect them with appropriate resources and services. The Care Manager advocates for individuals, helps them navigate the healthcare and social service systems, and monitors their progress towards housing stability and improved well-being. The team will follow street homeless individuals in the community to provide intensive outreach, engagement, and care coordination services. The role will require field-based work, on call coverage, and a willingness to work flexible hours.

Primary Duties & Responsibilities include, but are not limited to:

• Conduct outreach to locate and engage street homeless individuals in need of immediate assistance.

• Build rapport and establish trusting relationships with individuals experiencing homelessness, providing support, empathy, and guidance.

• Connect homeless individuals with available shelter or emergency housing resources, ensuring their safety and immediate needs are addressed.

• Collaborate with community partners, including shelters and housing providers, to facilitate access to appropriate services and resources.

• Engagement beginning either at known “hang-outs” or “Hot spots” within the transit system or during an inpatient hospital admission or emergency department visit with involvement in transition planning, including a needs assessment of community transition supports essential to stabilizing the participant;

• Outreach to communities, Street Outreach Teams, police, hospitals, providers, and community/family members and other caregivers to help identify individuals who would benefit from referral to a SOS CTI Team

• Individual sessions with participants emphasizing prevention and preparing for independent community living and the promotion of optimum mental and emotional health. May require helping participants deal with issues associated with but not limited to family and social relationships; stress and symptom management; activities of daily living; medication management; and housing readiness;

• Work with participants and their housing providers to resolve clinical issues that are impacting on the participant’s ability to obtain, manage, and retain supportive housing;

• Foster connection and engagement with community-based organizations that promote a sense of purpose, physical wellness, education, employment, socialization, and community involvement;

• Engage in ongoing assessment and resolution of participants immediate needs including but not limited to health, safety, clothing, food, income/benefits, and shelter.

• Community navigation including accompanying to first behavioral health and medical appointment, travel training, reengagement in community care, referral to services with ability to identify and address potential services and barriers to obtain and maintain such services;

• Establish collaborative working relationships with referring treatment teams and other partners and plan with them for appropriate discharges for participants;

• Provide intensive emotional and practical support to participants as they transition back into their communities;

• Provide on-call after hour crisis intervention services when needed to participants and their support network, including respite referrals and other diversion and stabilization services;

• Respond to requests from SOS on Call line for individuals in need

• Attend and participate in team meetings and supervisory sessions;

• Review documentation and conduct comprehensive psychosocial assessments to determine the medical, psychiatric, housing and other social needs in the community;

• Develop short-term person-centered care plans to assist participant towards achieving their goals;

• Monitor and record participant’s progress and modify plan according to needs and preferences;

• Timely and accurate documentation of participant information within Health Information Technology platform

• Skill building with participants to assist in attending to daily living skills such as personal hygiene, grooming and laundry, nutrition/meal preparation, budgeting, and socialization tasks and skills needed to successfully live and work in the community environments of their choice and also in maintaining a safe living environment;

• Comply with all required in-service training and staff development;

• Perform other related duties as assigned;

Qualifications/Criteria:

2 years of case management work experience in a social service agency, preferable serving a behavioral health population. Knowledge of mental illness and the needs of individual living with severe and persistent mental illness. Demonstrated competency in written, verbal and computational skills to present and document records in accordance with program standards.

• Flexibility to work overnight hours, including weekends and holidays, as needed to ensure 24-hour coverage and support for the SOS program.

• Knowledge of mental illness and serious emotional disturbances and substance use disorders;

• In depth knowledge of NYC behavioral health and community support programs and systems.

• Knowledge of homeless resources, NYC shelter systems, and MTA transit systems.

• Experience working with homeless and precariously housed populations.

• Knowledge of treatment, rehabilitation, and community support programs as they relate to consumers/residents, families, and staff;

• Knowledge of multi-disciplinary team experience, preferred;

• Knowledge of techniques for identifying and preventing potentially violent behavior, including crisis management techniques;

• Ability to develop, evaluate, implement and modify a clinical treatment intervention to meet the needs of individual participants;

• Ability to prepare accurate and timely reports;

• Ability to manage multiple projects and ask for help when needed;

• Computer proficiency in Electronic Health Records and Microsoft applications such as MS Word, Excel, PowerPoint

• Ability to utilize strength-based and recovery-oriented approaches (I.eHarm reduction, motivational interviewing, trauma informed care)

• Ability to communicate effectively with stakeholders;

• Competency in written, interpersonal, verbal and computational skills to present and document records in accordance with program standards;

• Preferred familiarity with systems and tools commonly utilized across HH programs (i.e MAPP, UAS, EMEDNY, PSYCKES).

• Available to work a flexible schedule in response to participant and staff needs

This position requires travel throughout the five boroughs of New York City.

Education: Bachelor’s degree or higher, preferably in psychology, social work, sociology, or related field or be a New York State Licensed Practical Nurse (LPN).

Job Type: Part-time

Pay: $55,000.00 per year

Benefits:

• 403(b)
• 403(b) matching
• 457(b)
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Schedule:

• 8 hour shift

Ability to Relocate:

• New York, NY: Relocate before starting work (Required)

Work Location: In person