Outreach Case Manager - PSH

Woodley House•Washington, DC

About The Position

The Outreach Case Manager works with chronically homeless families who are unengaged or disengaged from services. The role develops and maintains a caseload as clients are located and re-engaged, providing recovery-oriented case management using practices such as Housing First, Motivational Interviewing, Harm Reduction, Assertive Engagement, Recovery-Oriented Mental Health Services, Crisis Intervention, and Trauma-Informed Care. Through proactive, field-based outreach and coordination with shelters, hospitals, jails and detention centers, and treatment facilities, the Case Manager locates clients, rebuilds trust, supports housing stabilization, and transitions clients back to standard case management with continuity of care. The position provides assessments, individualized outreach and care plans, crisis intervention, resource connection, housing navigation, and ongoing support through housing stabilization. It coordinates closely with clients, Case Managers, supervisors, and community partners, while maintaining accurate records and documentation in accordance with program, funder, regulatory, and HIPAA requirements. The role also participates in case conferences, staff and treatment-team meetings, trainings, community events, and quality improvement activities. This position involves regular community and in-home services, field-based outreach in diverse and sometimes unpredictable environments, and travel to multiple sites in Washington, DC. The schedule must be flexible to include some evenings and/or weekends as needed for client engagement and outreach.

Requirements

Bachelor's degree required; a degree in a related field is preferred, plus one year of experience providing case management services.
In lieu of the education requirements, a high school diploma or equivalent plus four years of experience working with vulnerable and marginalized populations is accepted.
Strong engagement and rapport-building skills with hard-to-reach or reluctant populations, including working knowledge of Motivational Interviewing, Harm Reduction, and Assertive Engagement.
Ability to locate clients and track their status through coordination with shelters, hospitals, correctional facilities, substance use disorder treatment providers, and other service systems.
Ability to work independently and as part of a team and exercise mature judgment.
Ability to provide community and in-home services regularly, including field-based outreach in diverse and sometimes unpredictable environments.
Strong communication skills.
Ability to manage a caseload and coordinate multiple projects or tasks simultaneously in a high-pressure environment.
Computer proficiency, including Microsoft Office, Zoom, and electronic health record systems.
Flexibility to work some evenings and/or weekends as needed for client engagement and outreach.
Valid driver's license and willingness to drive to multiple sites in Washington, DC for home visits and outreach.
Physical ability to sit, stand, climb stairs, walk, drive, carry and lift 20 pounds, operate a computer keyboard, grasp firmly, perform repetitive hand control, complete forms in personal writing, make and receive telephone calls, and use general office equipment.
Ability to work subject to outside environmental conditions during field-based outreach and home visits.

Nice To Haves

Related-field degree.
Experience in homeless services, case management, mental health, substance use treatment, permanent supportive housing, or community-based outreach serving families.

Responsibilities

Identify, develop, and maintain a caseload of clients who are unengaged or disengaged from services, including clients facing barriers such as lack of communication access, incarceration, hospitalization, or treatment admission.
Conduct proactive street- and community-based outreach, home visits, visits to known locations, and outreach coordinated with shelters, hospitals, jails, detention centers, and treatment facilities.
Build and maintain relationships with community partners to track client status and facilitate warm hand-offs following release or discharge.
Complete initial comprehensive and re-engagement assessments, and develop individualized outreach, re-engagement, and care plans with clients and assigned Case Managers.
Use low-barrier, evidence-based engagement practices, including Motivational Interviewing, Harm Reduction, Assertive Engagement, and Recovery-Oriented Mental Health Services.
Provide case management, crisis intervention, resource connection, and housing stabilization support until the client transitions to a standard caseload.
Assist clients with housing navigation, including obtaining documents needed for housing vouchers and finding apartments to lease.
Monitor client progress and plan outcomes through housing navigation and stabilization, adjusting support as needed.
Conduct in-person meetings and the required number of monthly contacts according to regulations, and more often when needed.
Provide therapeutic supportive case management addressing mental health, functional, and housing barriers.
Coordinate with Case Managers to transition re-engaged clients to standard case management and support continuity of care.
Conduct crisis and risk assessments during outreach, provide appropriate interventions, consult with the supervisor, and complete critical incident reports within 24 hours.
Provide crisis intervention that supports clients' independent problem-solving, coping skills, and self-coordination of care.
Participate in regular case conferences with Case Managers and the Supervisor to review caseload status and adjust outreach strategies.
Document successful and unsuccessful outreach attempts, contacts, and re-engagement outcomes in the electronic health record in accordance with applicable standards.
Maintain accurate client status records and complete progress notes for every outreach attempt, client or collateral contact, and monthly summary reports as assigned.
Safeguard confidential client information in accordance with HIPAA standards.
Cooperate with compliance and quality improvement activities; participate in staff meetings, treatment-team meetings, and assigned trainings.
Represent the program at community outreach events, resource fairs, and provider meetings.
Perform additional related duties as assigned.