Case Manager (SOS) - Community Support Program

Scope of Position

The SOS team, consisting of a Director, Assistant Director, Clinicians, Care Managers, a Nurse, and a Peer Specialist, will apply the evidence-based Critical Time Intervention (CTI) model to support participants transitioning from the street to stable housing. The Case Manager will engage in community outreach, assist with daily living skills, accompany participants to appointments, and advocate for them against discrimination or healthcare inequities. The role emphasizes member choice, harm reduction, and person-centered care. SOS teams will continue supporting participants post-housing placement for several months to ensure stability and well-being.

Essential Position Functions

• Persistent and assertive outreach and engagement using strength-based approaches beginning either at known “hang-outs” or “Hot spots” within the transit system 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.
• Work in collaboration with the centralized SOR Hub to identify available housing and to support participants through the process. Tasks may include completing HRA 2010e, applying for housing, prepping for interviews, following up with housing providers, and assistance with moving in (day of move).
• Obtain housing supplies and learn the neighborhood.
• Participate in hospital discharge planning meetings to identify the best community resources for returning patients.
• Collections and reports data, as required, and works closely with team leaders, data analysts, and other SOS teams to use data to inform future care delivery.
• Once housed, work with participants and their housing providers to resolve clinical issues that are impacting on the participant’s ability to manage and retain supportive housing.
• Foster relationships with the community to ensure that recipients are connected with appropriate services as they transition back into the community.
• Appointment navigation, including accompaniment to appointments, travel 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 in the community.
• Obtain historical and collateral information from multiple sources to support the behavioral and physical health needs of participants.
• Monitor, evaluate, and record the progress of participants with respect to care plan goals.
• Attend and participate in team meetings and supervisory sessions.
• Perform other related duties as assigned.

Qualifications

• Bachelor’s Degree; Minimum three years of experience providing services to adults with serious mental illness preferred; Case Management work experience in a social service agency, preferably serving a behavioral health population; Four years of past work case management work experience may be considered in lieu of Bachelor’s degree.
• Experience working with homeless and/or precariously housed populations is preferred but not required.
• Knowledge of homeless resources, NYC shelter systems, and MTA transit systems is a plus.
• Knowledge of counseling principles and methods for mental illness and substance use disorders.
• Knowledge of treatment, rehabilitation, and community support programs as they relate to recipients/residents, families, and staff.
• Ability to develop, evaluate, implement, and modify treatment intervention to meet the needs of individual recipients.
• Ability to prepare accurate and timely reports.
• Computer proficiency and good documentation skills.
• Spanish speaking is highly desirable.

The Bridge Inc. is an Affirmative Action / Equal Opportunity Employer