Reentry Health Home Plus Care Manager

Housing Works • Queens, NY

78d • Hybrid

About The Position

The HH+ Case Manager works with members and the member’s network of providers to help minimize barriers to care and help members achieve improved health outcomes. Using interventions such as care coordination, motivational interviewing and health promotion. HH+ Case Managers help members, over the course of time, develop the skills needed to manage their health and psychosocial needs with greater independence. HH+ Case Managers will have the opportunity to work as part of outcome driven integrated team and participate in agency-wide quality improvement activities aimed at improving the delivery of care to individuals living with chronic illness, behavioral health issues, and homelessness. To ensure high-quality, person-centered care, Care Managers are expected to maintain an active and consistent field and office presence. Meaningful face-to-face interaction with clients and service providers is an essential, and required, component of this role and is critical to fostering engagement, coordinating care, and achieving positive health outcomes. At Housing Works, we believe our staff are one of our greatest assets. We demonstrate this commitment by offering a competitive salary, generous tuition reimbursement, and a robust benefits package, including opportunities for eligible team members to further their education and professional growth.

Requirements

• Adept with word processing, Excel, and Microsoft Office products
• Ability to communicate well both written and oral
• Good organizational and multi-tasking skills
• Positive attitude and adaptable with both staff and clients
• Highly organized with the ability to work independently and prioritize multiple responsibilities in a fast-paced environment
• Comfortable working with a diverse group of staff and clients
• Proficiency and comfort with online meeting software such as Zoom and Microsoft Teams
• Understanding of chronic medical conditions, homelessness, substance use and mental illness
• Knowledge of City, State, and Federal entitlement and benefit systems.
• Ability to travel within the boroughs via public transportation and ability to work from remote office locations.
• Requires access to email, phone, Zoom and Teams.
• Requires ability to comply with agency confidentiality guidelines in remote workspace

Nice To Haves

• Previous experience with Electronic Health Records a plus
• Spanish bilingual proficiency is preferred for this role. Candidates hired to support clients in Spanish are eligible for additional compensation.

Responsibilities

• Guides clients with chronic illness(es) and those with prior justice involvement through the health care system through direct, in-person engagement, hands-on care coordination, and ongoing relationship-building with clients and service providers.
• Reduces barriers to care, strengthens client participation in services, and tracks interventions and outcomes to support long-term stability and improved health outcomes.
• Conducts comprehensive in-person initial assessments and annual reassessments of clients’ medical, mental health, substance use, financial, housing, and support needs in community, home, clinical, or office-based settings.
• Manages a caseload of 20 clients with high level of care needs.
• Develops and maintains individualized, patient-centered plans of care with documented input and approval from clients and collaborating providers, updating care plans at least every 3–6 months or when new needs are identified, in accordance with Health Home standards.
• Collaborates closely with medical and behavioral health providers through face-to-face meetings and coordinated care activities to develop, implement, and monitor care plans for clients with chronic conditions such as diabetes, asthma, congestive heart failure, hypertension, behavioral health conditions, HIV, and other complex health needs.
• Engages clients in person to review housing options based on program eligibility and provides hands-on assistance with housing-related applications, including the 2010E (application submission and psychosocial completion), NYC Housing Connect, Section 8, and other relevant housing programs.
• Prepares and accompanies clients on apartment viewings, advocates with housing providers and landlords, and researches and provides housing resources to clients.
• Addresses benefits-related needs through direct client support, including Medicaid, HRA, SNAP benefits, medical transportation, and other entitlement programs, utilizing in-person advocacy and coordination when appropriate.
• Conducts regular home and field visits to maintain consistent client engagement, assess changing needs, and support progress toward care plan goals in accordance with Health Home program standards and client preferences.
• Coordinates client services with internal and external providers through regular, in-person or hybrid case conferencing, occurring at least quarterly, to ensure alignment, accountability, and continuity of care.
• Documents all in-person and care coordination activities, client outcomes, and care plan progress in the case record, ensuring timely and accurate documentation for the full caseload.
• Maintains strict confidentiality in all client interactions and records.
• Performs other duties as assigned.

Benefits

• Competitive salary
• Generous tuition reimbursement
• Robust benefits package
• Opportunities for eligible team members to further their education and professional growth
• Three comprehensive healthcare plans to choose from based on your priorities and budget. Housing Works covers most of the plan; you pay a portion, based on your salary.
• Staff begins accruing PTO immediately for a total of up to 30 days earned in the first year.
• Educational benefit: This money is available for tuition loan reimbursement, tuition costs, and textbooks.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed