Outreach Case Manager - Full Time

Rescue Mission•Syracuse, NY

13d•$25

About The Position

The SOS CTI Care Manager’s role will involve community outreach on the streets, coordinating members’ needs before and after their move from street to home, enhancing their daily living skills, accompaniment to appointments, and advocating on their behalf when faced with discrimination or healthcare inequities. Member choice, harm reduction, non-coercion, flexibility, and person-centered care are essential elements of the SOS program model and should be front and center of the care delivered by the Care Manager. This position works with substantial independence in the field, with consultation available from Team Lead, as needed.

Requirements

Bachelor’s degree or higher in Psychology, Social Work, Sociology, or related field required.
Minimum of two years of previous care management experience, working with the Medicaid population required.
Minimum of two years’ experience in providing advocacy services to people who are mentally ill and/or homeless required.
Valid NYS Driver’s License in compliance with company policy.
Must follow CDC guidelines regarding Covid-19, including but not limited to, wearing a mask when working.
Full vaccination against Covid-19, including Booster (when eligible) is strongly encouraged.

Responsibilities

Persistent and assertive outreach and engagement using strength-based approaches beginning either at known “hang-outs” or “hot spots” within the local communities 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 assessment tools for those identified as being at high risk.
Participate in hospital discharge planning meetings to identify the best community resources for returning members.
Assist with appointment navigation including accompaniment to appointments, transportation 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 of the member within the community.
Obtain historical and collateral information from multiple sources to support members behavioral and physical health needs.
Monitor, evaluate, and record participants progress with respect to care plan goals.
Adheres to Monroe Plan professional boundaries and protocols.
Adhere to program documentation requirements in the Electronic Health Record.
Work in collaboration with the regional partners to identify available housing and to support participants through the process. Tasks may include applying for housing, prepping for interviews, follow up with housing providers, and assistance with moving in (day of move) and with obtaining housing supplies and learning about the neighborhood.
Participate in hospital discharge planning meetings to identify the best community resources for returning members.
Once housed, work with members and their housing providers to resolve clinical issues that are impacting the member’s ability to manage and retain supportive housing.
Foster relationships with community providers to ensure that members are connected with appropriate services as they transition back into the community.
Document a Person-Centered Care Plan, in collaboration with the client and providers.
Collect and report data, as required and work with team leader and other SOS staff to use data to inform future care delivery.
Provide program information to members and providers, and other organizations as requested to introduce and support program participation.
Contributes to team effort by accomplishing related results as needed/assigned.
Regular and predictable attendance is an essential requirement of the job
Promotes a safety-first attitude by setting a positive example and ensuring all employees are following safety policies and procedures.
Perform other duties as assigned.