Case Manager, Safe Options Support (SOS)

ACMH INC•New York, NY

2d•Onsite

About The Position

The Case Manager, Safe Options Support (SOS) position involves community outreach on the streets and subways, coordinating participants' needs before and after their transition from street to home, enhancing their daily living skills, providing supportive counseling, and advocating on their behalf when faced with discrimination or healthcare inequities. The role requires persistent and assertive outreach, continuous assessment of health and social needs, collaboration with housing resources, participation in hospital discharge planning, data collection and reporting, and working with participants and providers to resolve clinical issues impacting housing retention. The position also involves fostering relationships with community providers, appointment navigation, conducting psychosocial assessments, obtaining collateral information, monitoring participant progress, and attending team meetings.

Requirements

Bachelor’s degree or higher, preferable in psychology, social work, sociology, or related field or be a New York State Licensed Practical Nurse (LPN).
Case Management work experience in a social service agency, preferable serving a behavioral health population.
Four years of past work case management work experience may be considered in lieu of Bachelor’s degree.
Computer proficiency and good documentation skills.

Nice To Haves

Experience working with homeless and/or precariously housed populations preferred but not required;
Knowledge of homeless resources, NYC shelter systems, and MTA transit systems a plus.
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 recipient/residents, families, and staff;
Ability to develop, evaluate, implement, and modify treatment intervention to meet the needs of individual recipients;
Ability to prepare accurate and timely reports;

Responsibilities

Persistent and assertive outreach and engagement using strength-based approaches beginning either at known “hang-outs” or “Hot spots” within the transit system or during an inpatient hospital admission or emergency department visit;
Continuously assess the health and social needs of participants through SOS’s conversational and observational assessments and formalized risk assessments tools for those identified as being at high risk;
Work in collaborations with the centralized SOR Hub to identify available housing and to support participants through the process. Tasks may include completing HRA 2010e, applying for housing, prepping for interviews, follow up with housing providers, and assistance with moving in (day of move) with obtaining housing supplies and learning the neighborhood;
Participate in hospital discharge planning meetings to identify the best community resources for returning patients;
Collects and reports data, as required and work with team leader, data analyst and other SOS teams to use data to inform future care delivery;
Once housed work with participants and their housing providers to resolve clinical issues that are impacting on the participant’s ability manage, and retain supportive housing;
Foster relationship with community provides to ensure that recipients are connected with appropriate services as they transition back into the community;
Appointment navigation including accompaniment to appointments, travel training, reengagement in community care, and addressing barriers to care;
Review documentation and conduct comprehensive psychosocial assessments to determine the medical, psychiatric, housing and other social needs in the community;
Obtain historical and collateral information from multiple sources to support participants behavioral and physical health needs;
Monitor, evaluate and record participants progress with respect to care plan goals;
Attend and participate in team meetings and supervisory sessions.
Perform other related duties as assigned.