Care Manager

About the role

A Care Manager at Housing Works holds a deeply rewarding, hands‑on role supporting individuals with complex medical, behavioral health, and social service needs. Care Managers are at the forefront of the mission, working directly with clients to help them navigate systems of care, overcome barriers, and achieve meaningful, client‑defined goals as part of a thriving and growing organization. This role offers the opportunity to develop strong clinical and engagement skills within a multidisciplinary team that includes medical providers, behavioral health professionals, supervisors, and community‑based partners. While Care Managers maintain a level of professional autonomy, the work is rooted in accountability, responsiveness, and consistent, direct client contact as the foundation of effective care management. Care Managers serve as the primary point of contact for their assigned clients and are responsible for building trusting, sustained relationships through regular in‑person engagement. This includes meeting clients in their homes, communities, healthcare settings, and the office to conduct assessments, coordinate services, and support ongoing care planning. 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 component of this role and is critical to fostering engagement, coordinating care, and achieving positive health outcomes.

Responsibilities

• Conduct 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.
• Develop and maintain 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.
• Collaborate 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.
• Engage clients in person to review housing options based on program eligibility and provide 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.
• Address 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.
• Conduct 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.
• Coordinate 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.
• Document 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.
• Maintain strict confidentiality in all client interactions and records.
• Perform other duties as assigned.

Requirements

Bachelor’s Degree with 2 years related experience or a Masters Degree with one year of relevant experience.

Ability to travel within the boroughs