Case Manager – High Risk Populations (Housing Support)

Central Health•Austin, TX

12d

About The Position

Central Health’s High Risk Populations Department provides patient-centered care for people experiencing homelessness and housing instability, combining health services with intensive case management, emergency shelter support, and social-service coordination. The Case Manager may support one or more programs, including the Bridge Program, Medical Respite, and Housing Support Program. The Bridge Program provides short-term transitional medical care and intensive case management through a fixed clinic and mobile outreach locations. Medical Respite offers temporary accommodation and medical oversight for people recovering from illness, injury, or hospitalization, alongside case management and support with housing, benefits, and community resources. The Housing Support Program helps individuals transition into stable housing through intensive case management, move-in readiness support, home visits, and skills training. As a member of a multidisciplinary team, the Case Manager provides intensive, trauma-informed case management across clinic sites, mobile locations, and respite settings. The role supports crisis management, advocacy, referrals, benefits access, and identification of safe, affordable housing, with the aim of improving health outcomes, stability, and self-sufficiency.

Requirements

Bachelor’s degree in Social Work or a related field; a higher degree is accepted.
Internship or work experience in a field related to social work, case management, or counseling individuals in crisis or trauma situations.
Knowledge of community resources and how to access them for clients’ benefit.
Valid driver’s license.
Basic Life Support certification.
Strong relationship-building and patient-support skills.
Strong problem-solving skills.
Attention to detail and accuracy.
Excellent verbal and written communication skills.
Success collaborating with multidisciplinary team members.
Knowledge of evidence-based practices used in case management, crisis intervention, and work with the populations served.
Knowledge of mental health and substance-use diagnoses, trauma-informed care, patient engagement, motivational interviewing, and cultural competency.

Nice To Haves

Bilingual in Spanish and English.

Responsibilities

Conduct whole-person assessments of clients’ strengths, barriers, mental health needs, and readiness to change.
Provide crisis intervention, including assessment, risk evaluation, safety planning, referrals, and follow-up.
Develop individualized care plans with patients addressing mental health, medical needs, and social determinants of health.
De-escalate heightened situations involving trauma, exacerbated mental health symptoms, and behavioral complexity using a trauma-informed approach.
Provide goal-oriented, solution-focused services and evidence-based interventions for mental health and psychosocial needs.
Educate patients about community resources and collaborate with them to access those resources, advocating for and coordinating community supports and services.
Teach and guide patients through structure and modeling, including helping them follow through on tasks.
Help patients identify and manage barriers to navigating health services and government benefits.
Accompany patients to appointments as needed.
Assist patients directly or indirectly with housing surveys, including Coordinated Assessment.
Support discharge planning by reviewing transitional housing options, assisting with room-rental searches, and helping with housing applications.
Collaborate with housing specialists and other resources to identify and address psychological, social, and medical needs and coordinate housing-program referrals.
Collaborate and advocate with patients’ interdisciplinary teams, community resources, and partner agencies.
Participate in interdisciplinary case conferences to support coordinated patient care.
Assist other teams within the department as needed.
Complete documentation in a timely manner.
Perform other duties as assigned.