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About the Role
Experienced Case Manager to work on a newly funded innovative Care Transition team serving participants transitioning to the community from a higher level of care or those unconnected to care. The role involves facilitating transitions by addressing preparatory needs, discharge planning, and developing daily living skills through individual work in the community. The team follows participants into the community using the SOS model (Critical Time Intervention) to ensure linkage and engagement with community providers and sufficient support networks. The role requires on-call coverage, flexible hours, and community outreach to engage individuals experiencing homelessness.
Responsibilities
- Engagement beginning from referring location with involvement in transition planning, including a needs assessment of community transition supports essential to stabilizing the participant
- Individual sessions with participants emphasizing prevention and preparing for independent community living and the promotion of optimum mental and emotional health
- Work with participants and their housing providers to resolve clinical issues impacting their ability to obtain, manage, and maintain supportive housing
- Community navigation including accompanying to first behavioral health and medical appointments, travel training, reengagement in community care, referral to services with ability to identify and address potential services and barriers
- 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 assigned) to participants and their support network, including respite referrals and other diversion and stabilization services
- 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
- In collaboration with credentialed colleagues, assesses and monitors participant behavior in accordance with 9.58 regulations
- Participate in identifying available shelter/Safe Haven bed during canvassing activities
- Monitor and record participant’s progress and modify plan according to needs and preferences
- Timely and accurate documentation of participant information within the electronic platform
- Assist and instruct Participants 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
Requirements
- Minimum 5 years’ experience can replace degree
- 2 years of case management work experience in a social service agency, preferably serving a behavioral health population
- Knowledge of mental illness and the needs of individuals 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
- Requires the ability to canvass in subway stations, take and manage public transportation and travel/visit shelters, safe havens, and all other temporary and permanent style dwellings
- Requires travel throughout New York City
Skills
- Critical Time Intervention
Location
- New York, NY
Work Type
- Full-Time
- Onsite
Experience Level
- 2 years of case management work experience
Education Level
- Bachelor’s degree required
Salary/Compensations
- $24.73 - $24.73 Hourly