Case Manager Lead – High Risk Populations (Respite/Bridge)

Central Health•Austin, TX

20h

About The Position

Central Health’s High Risk Populations Department provides innovative, patient-centered care to individuals experiencing homelessness and housing instability. These programs address gaps in medical care by combining access to health services with intensive case management, emergency shelter support, and coordination of social services. This role will be expected to support one or more programs including The Bridge Program, Medical Respite, Housing Support Program, and more. The Bridge Program includes a short term, transitional clinic designed to bridge gaps in care for individuals who lack consistent access to primary or specialty medical services. Operating out of a Central Health’s clinic location and through mobile outreach sites, the Bridge Program provides low-barrier medical care and intensive case management for patients experiencing homelessness or housing instability. The program focuses on stabilization, engagement, and connection to a long-term medical home, ensuring continuity of care while addressing immediate health and social needs. The Medical Respite Program provides a safe, temporary place for individuals experiencing homelessness to recover from acute illness, injury, or hospitalization while receiving ongoing medical oversight and case management support. Medical Respite offers access to emergency shelter, coordinated medical and behavioral health services, and daily engagement from a multidisciplinary care team. During their stay, patients are supported in improving their health while also addressing critical social needs such as housing placement, benefits enrollment, and linkage to community resources to promote long-term stability. The Housing Support Program supports individuals in their transition into transitional or stable housing by providing intensive case management support with the goal of housing independence. The team will be expected to perform move-in readiness, home visits, and providing skills training. The Case Manager Lead plays a critical role in providing case management services while also supporting and coordinating staff across various High Risk Population sites to ensure the successful completion of program objectives and compliance with organizational rules and regulations. In this position, the Case Manager Lead works closely with the High Risk Population Case Management Manager to lead and support case management programs tailored to individuals who are especially vulnerable or high-risk. The role also includes applying trauma informed empowerment-based prevention and intervention strategies to enhance community health outcomes and addresses psychosocial needs with patients.

Requirements

High level of skill at building relationships and providing excellent patient support.
Client Service and Problem Resolution: Ability to handle patients concerns and complaints in a professional and timely manner, ensuring all issues are addressed and resolved effectively.
Confidentiality: Ensure the confidentiality of all patients information, adhering to all privacy and security protocols.
Leadership: Strong skills to oversee and support case managers and community health workers effectively providing training and development, and enforce Central Health policies and procedures.
Team Collaboration: Ability to work collaboratively with multidisciplinary team, leadership, and community partners to ensure a seamless operational flow.
Crisis Management: Ability to assess situations and manage crises, using trauma informed care and making quick and informed decisions when necessary.
Demonstrated knowledge of the current homeless service system in Travis County.
Demonstrated knowledge of community resources available and how to access resources for our patient population.
Demonstrated success in collaborating with other healthcare and social service organizations.
Provide leadership, direction and support of assigned team members.
Coach and mentor team members.
Train team members in performance of job duties, assign job tasks, and monitor completion.
Education: Bachelor's Degree (higher degree accepted)- Bachelor's degree in social work or related field, or 5 years of experience working with vulnerable populations including but not limited to persons experiencing homelessness in the lieu of the degree.
Work Experience: 3 or more years of experience working with vulnerable populations including but not limited to persons experiencing homelessness
Licenses and Certifications: Valid drivers license Upon Hire
Basic Life Support Upon Hire -Required

Responsibilities

Conduct biopsychosocial assessments to determine patient’s strengths, barriers, mental health needs, and readiness to change.
Develops individualized care plans in collaboration with patients, that address mental health, medical, and social determinants of health.
Provides crisis intervention services (assessment, evaluation of risk, safety planning, referral, and follow up)
Effectively de-escalate heightened situations with patients experiencing trauma, exacerbated mental health symptoms, and behavioral complexity while using a trauma informed care approach.
Provides goal oriented and solution focused services and evidenced based interventions (engagement, case management, counseling linkage) to patients with complex psychosocial needs.
Educates and works collaboratively with patients on available community resources while advocating and helping to coordinate with community supports and services.
Teaches patients through structure and modeling appropriate expectations and guide them on following through with their tasks.
Helps patients identify and manage challenges or barriers in navigating health and government benefits.
Accompany patients to appointments as needed.
Assists patients directly or indirectly with housing survey (Coordinated Assessment)
Works with patients on discharge planning by reviewing potential transitional housing programs, assisting with room rental search and applications for housing units.
Collaborate with housing specialists and/or other resources to identify and address psychological, social and medical needs, and coordinates referrals for housing programs.
Works collaboratively and advocates with patient’s interdisciplinary team, community resources, and partner agencies.
Support team members with de-escalating patients as needed.
Completes clinical documentation in a timely manner.
Assists other team within the department as needed.
Assist in adherence to monthly schedules for staff.
Collaborates with the Case Management Manager to support onboarding and training to staff.
Updates relevant procedures and resource guides.
Collaborates wtih the Case Management Manager on the performance evaluation of staff.
Other duties as assigned.