Complex Needs Case Manager

FIRST PRESBYTERIAN CHURCH•Dallas, TX

3d•Onsite

About The Position

The Complex Needs Case Manager provides intensive, person-centered case management to neighbors experiencing homelessness who have high and complex service needs, including serious mental health needs, chronic health conditions, housing instability, and other barriers to achieving and maintaining housing stability. As a member of The Stewpot team, and under the program direction and coordinated care framework of Housing Forward, the Case Manager works with partner agencies and community providers. The role serves neighbors who may need more coordination and engagement than traditional case management, building trusting relationships, developing individualized service plans, coordinating care across systems, reducing barriers to housing and services, and supporting housing stability, improved wellness, and independence. The position includes helping neighbors obtain or replace essential identification documents; coordinating behavioral health, medical, substance-use, benefits, and other services; supporting housing placement and stability; responding appropriately to crises; and maintaining accurate case records and program data. The Case Manager uses a person-centered, trauma-informed, strengths-based, and housing-focused approach, and coordinates with qualified professionals rather than providing clinical services outside the role's scope.

Requirements

Bachelor's degree in Social Work, Psychology, Sociology, Human Services, Behavioral Health, or a related field is preferred; equivalent relevant experience may be considered.
Knowledge of homelessness, housing systems, behavioral health services, healthcare resources, and community-based services.
Demonstrated ability to work effectively with individuals who may be difficult to engage through traditional service models.
Strong crisis-management, problem-solving, communication, and interpersonal skills.
Ability to coordinate effectively across multiple organizations and disciplines.
Strong documentation and organizational skills.
Ability to maintain appropriate professional boundaries and confidentiality.
Valid driver's license and ability to travel throughout the community as required.

Nice To Haves

Experience providing case management to individuals experiencing homelessness, serious mental health needs, behavioral health challenges, or other complex circumstances.
Experience with HMIS or comparable case-management systems.

Responsibilities

Maintain an assigned caseload of neighbors identified as having high or complex service needs.
Build trusting, consistent relationships with neighbors who may have difficulty engaging with traditional service systems.
Assess identification needs, barriers, and eligibility requirements; develop action plans; and assist with applications for essential documents such as birth certificates, state-issued identification cards, and Social Security cards.
Help neighbors gather required documentation, complete forms, schedule appointments, and navigate government and community service systems; follow up with neighbors and providers to address barriers.
Develop individualized service plans based on neighbors’ priorities, strengths, barriers, and housing goals.
Provide person-centered, trauma-informed, strengths-based, and housing-focused case management to address barriers to housing placement and stability.
Coordinate with neighbors and qualified behavioral health and healthcare professionals regarding mental health, substance-use, chronic medical, and other complex needs.
Recognize circumstances that may require clinical, medical, or crisis intervention and facilitate connections to treatment, primary care, medication management, substance-use services, benefits, and other resources.
Participate in multidisciplinary discussions about neighbors with particularly complex needs.
Coordinate with community partners to support appointment attendance, including transportation arrangements, reminders, and follow-up.
Connect neighbors experiencing housing instability to emergency and ongoing supportive services and available community resources.
Connect neighbors with food pantries, meal programs, food assistance benefits, clothing, hygiene products, household essentials, and other basic-needs supplies.
Coordinate with Housing Forward, housing providers, landlords, and other partners involved in neighbors’ housing plans.
Support newly housed neighbors as they transition from homelessness into housing; identify risks of housing loss and coordinate early interventions.
Help neighbors develop skills and connections that support long-term housing stability.
Recognize and respond appropriately to behavioral health crises and other situations requiring immediate intervention, following established protocols and coordinating with appropriate professionals, emergency services, or other resources.
Maintain professional boundaries and communicate significant safety concerns; complete incident reports and required follow-up documentation.
Maintain timely, accurate case notes and document assessments, contacts, referrals, services, progress, barriers, and outcomes.
Enter required information into HMIS or other designated systems and maintain records required for grants, contracts, audits, and program compliance.
Protect confidential neighbor information and follow applicable privacy requirements.
Track neighbor progress from engagement through housing placement and stabilization; participate in case reviews and quality-assurance activities.