Care Manager - Safe Options Support

Elm & Oak Health•Elmira, NY

3d•Remote

About The Position

Elm & Oak Health is seeking a Care Manager for its Safe Options Support (SOS) program serving individuals experiencing homelessness in Chemung County. The role provides hands-on, person-centered care coordination and community outreach to help members access services, transition from the street to housing, and maintain stability. The program emphasizes member choice, harm reduction, non-coercion, flexibility, and person-centered care. The Care Manager works with substantial independence in the field, with consultation available from a Team Lead as needed. This is a full-time, work-from-home position requiring frequent travel throughout Chemung County, including regular visits to members’ homes. The stated annual salary range is $46,948–$57,380. Elm & Oak Health describes its benefits package as comprehensive, subject to eligibility requirements, and also offers non-monetary perks. The role includes outreach and engagement, coordination with members and providers, reporting, and communication. The Care Manager may not perform tasks governed by a professional license or registration, transport active Elm & Oak Health members, or provide hands-on care.

Requirements

Bachelor’s degree or higher in Psychology, Social Work, Sociology, or a related field.
At least two years of care management experience working with the Medicaid population.
At least two years of experience providing advocacy services to people who are mentally ill and/or homeless.
Knowledge of homeless resources, shelter systems, and transportation systems.
Knowledge of counseling principles and methods for mental illness and substance use disorders.
Knowledge of treatment, rehabilitation, and community support programs as they relate to recipients or residents, families, and staff.
Ability to develop, evaluate, implement, and modify treatment interventions to meet individual needs.
Ability to prepare accurate and timely reports.
Ability to respect individual and family diversity and maintain confidentiality.
Ability to work as a team member and collaboratively with providers and county or community health and human services.
Excellent oral and written communication and interpersonal skills.
Ability to work independently and manage time appropriately; strong organizational skills.
Computer literacy and ability to pass computer documentation competency testing for program software platforms.
Valid New York State driver’s license and ownership of, or access to, reliable transportation for job travel, including daily member-home visits.
Must not perform tasks governed by professional license or registration, transport active Elm & Oak Health members, or provide hands-on care.

Responsibilities

Conduct persistent, assertive, strength-based outreach and engagement in community locations and during hospital or emergency department visits.
Assess participants’ health and social needs using conversational and observational assessments and formal risk assessment tools when indicated.
Participate in hospital discharge planning to identify community resources for members returning to the community.
Help members navigate appointments through accompaniment, transportation training, re-engagement with community care, and addressing barriers to care.
Review documentation and conduct comprehensive psychosocial assessments of members’ medical, psychiatric, housing, and other social needs.
Obtain historical and collateral information from multiple sources to support members’ behavioral and physical health needs.
Monitor, evaluate, and document participants’ progress toward care plan goals while following professional boundaries and protocols.
Collaborate with regional partners to identify housing and support members with applications, interview preparation, follow-up with housing providers, moving in, obtaining supplies, and learning about the neighborhood.
Work with housed members and housing providers to resolve clinical issues that affect the member’s ability to manage and retain supportive housing.
Build relationships with community providers and connect members with appropriate services as they transition back into the community.
Develop a Person-Centered Care Plan in collaboration with the client and providers.
Collect and report data, and work with the Team Lead and SOS staff to use data to inform care delivery.
Follow program documentation requirements in the Electronic Health Record and provide program information to members, providers, and other organizations as requested.
Communicate professionally with members and community providers, provide feedback about member progress and barriers, and use listening skills to support engagement and person-centered planning.
Attend and participate in team meetings and supervisory sessions.
Perform other duties as assigned.