Case Manager – High Risk Populations (Housing Support)

Central Health•Austin, TX

11d

About The Position

The Case Manager is a key member of Central Health’s High Risk Populations multidisciplinary team, providing intensive, trauma-informed case management to patients served through the Bridge, Medical Respite, and Housing Support Programs. The role supports individuals experiencing homelessness or housing instability by addressing immediate health and social needs, promoting stability and self-sufficiency, and connecting patients to ongoing care and community resources. Work takes place across fixed clinic sites, mobile locations, and respite settings. Housing Support duties include move-in readiness, home visits, and skills training.

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; experience requirement is listed as less than one year.
Demonstrated knowledge of community resources and how to access them for clients’ benefit.
Valid driver’s license.
Basic Life Support certification.
Strong relationship-building skills and ability to provide excellent patient support.
Strong problem-solving skills.
Attention to detail and accuracy.
Excellent verbal and written communication skills.
Demonstrated ability to collaborate with multidisciplinary team members.
Strong knowledge of evidence-based practices commonly used in case management and crisis intervention, and of the populations served.
Strong 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 to determine 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, or behavioral complexity using a trauma-informed approach.
Provide goal-oriented, solution-focused services and evidence-based interventions to address mental health and psychosocial needs.
Educate patients about community resources, advocate for them, and help coordinate community supports and services.
Teach and guide patients through structure and modeling, setting appropriate expectations and supporting follow-through on tasks.
Help patients identify and manage challenges or barriers to navigating health care and government benefits.
Accompany patients to appointments as needed.
Assist patients directly or indirectly with housing surveys (Coordinated Assessment).
Support discharge planning by reviewing transitional housing programs, 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 referrals to housing programs.
Work collaboratively with and advocate alongside patients’ interdisciplinary teams, community resources, and partner agencies.
Participate in interdisciplinary case conferences to support coordinated patient care.
Assist other department teams as needed.
Complete documentation in a timely manner.
Perform move-in readiness activities, home visits, and skills training for the Housing Support Program.
Perform other duties as assigned.