Care Manager - Safe Options Support

Elm & Oak Health•Hornell, NY

6d•Remote

About The Position

Elm & Oak Health is seeking a Care Manager for its Safe Options Support (SOS) program, serving individuals experiencing homelessness in the Steuben County area. This full-time, work-from-home position requires frequent travel throughout Steuben County and substantial independence in the field, with consultation from a Team Lead as needed. The Care Manager conducts community outreach, coordinates care and essential services, supports participants as they move from the street into housing, helps build daily living skills, accompanies participants to appointments, and advocates when they encounter discrimination or healthcare inequities. The program emphasizes member choice, harm reduction, non-coercion, flexibility, and person-centered care. The Care Manager works with members, hospitals, housing providers, regional partners, community providers, and SOS colleagues to identify needs and coordinate services. The role includes assessing health and social needs, supporting discharge planning and housing transitions, documenting person-centered care plans and progress, and reporting program data. The position cannot perform tasks governed by a license or registration, transport active Elm & Oak Health members, or provide hands-on care. A bachelor’s degree or higher in a related field, relevant care management and advocacy experience, and a New York State driver’s license with access to reliable transportation are required.

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 and computer literacy.
Ability to pass computer documentation competency testing for all software platforms used within the program.
New York State driver’s license and ownership of or access to reliable transportation to meet travel requirements, including daily visits to members’ homes.
Willingness to travel regularly throughout Steuben County.

Responsibilities

Conduct persistent, assertive, strength-based community outreach and engagement, including at community hot spots and during hospital or emergency department visits.
Assess participants’ health and social needs using conversational and observational assessments and formal risk assessment tools when appropriate.
Participate in hospital discharge planning and identify community resources for members returning to the community.
Support appointment navigation, including accompaniment, transportation training, re-engagement with community care, and addressing barriers to care.
Review records 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 help participants apply, prepare for interviews, follow up with housing providers, move in, obtain supplies, and learn about their neighborhood.
Work with housed members and housing providers to address clinical issues affecting members’ ability to manage and retain supportive housing.
Build relationships with community providers and connect members with appropriate services during community transitions.
Develop and document Person-Centered Care Plans collaboratively with members and providers.
Collect and report data, and work with the Team Lead and SOS staff to use it 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 on member progress and barriers, and use listening skills to support engagement and person-centered planning.
Attend and participate in team meetings and supervisory sessions, and perform other duties as assigned.