Housing Taskforce Care Manager (LMSW or LCSW)

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, and the Essential Plan. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth’s network includes over 27,000 primary care providers, specialists, and participating clinics. For more than 30 years, MetroPlusHealth has built strong relationships with its members and providers.

About the role

Under the direction of the Manager of Housing Taskforce, the Housing Taskforce Care Manager provides critical support to members experiencing homelessness to optimize their healthcare and delivery of care experience, with expected cost savings due to improved quality of care. They also support formerly homeless members transitioning to permanent housing. This is accomplished through holistic, focused engagement and understanding of the member’s physical, behavioral, and social needs; environment; providers; support system; and available resources/services. The role is a hybrid remote/office/field position requiring travel within the MetroPlusHealth service area, including home visits, facility visits, and community-based agency visits.

Responsibilities

• Assess and address member’s problems and needs: clinical, psychosocial, financial, environmental
• Provide services to members of varying age, clinical scenario, culture, financial means, social support, and motivation
• Engage members in a collaborative relationship, empowering them to manage their physical, psychosocial, and environmental health to improve and maintain lifelong well-being
• Support members through the transitional period from shelter to permanent housing and once housed to settle into their new living situation
• Assess and address risks and gaps in care
• Maximize member’s access to available resources
• Develop a member-centered plan of care with input from member, caregivers, and healthcare providers, integrating cultural sensitivity and privacy practices
• Communicate plan of care to Primary Care Physician initially and provide updates as needed
• Ensure member’s understanding as it relates to language barriers, stress reaction, or cognitive limitations/barriers using verbal and nonverbal techniques
• Train member on relevant chronic diseases, preventive care, medication management (medication reconciliation and adherence), home safety, etc.
• Provide complex care management, including ensuring access to care, reducing unnecessary hospitalizations, and appropriately referring to community supports
• Advocate for members by assisting them to address challenges and make informed choices regarding clinical status and treatment options
• Develop collaborative relationships with clinical providers and facility staff
• Employ critical-thinking and judgment when dealing with unplanned issues
• Use data as a tool in tracking and trending outcomes and clinical information
• Maintain accurate, comprehensive, and current clinical and non-clinical documents
• Comply with all initial, annual, and other mandatory trainings, organizational and departmental policies, and procedures, and actively participate in the evaluation process
• Maintain professional competencies as a Housing Taskforce Care Manager
• Conduct other duties as assigned by Manager of Housing Taskforce

Requirements

• Master’s Degree in Social Work required
• 3 years of prior experience in care management in a healthcare and/or managed care setting, or other relevant experience working in the field of Social Work or Case Management
• Valid New York State license and current registration to practice as a Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) issued by the New York State Education Department (NYSED)
• Proficiency with computers, navigating multiple systems and web-based applications, including Microsoft Word, Excel, Teams, PowerPoint, Outlook, and various web-based portals
• Ability to travel within the MetroPlusHealth service area, including home visits, facility visits, and visits to community, faith, and other social service-based agencies
• Ability to proficiently read and interpret medical records, claims data, pharmacy and lab reports, and prescriptions
• Significant experience working with clients around issues of homelessness, addictions, mental health, entitlements, and housing
• Working knowledge of members’ rights and responsibilities as tenants
• Experience working on-site in a behavioral health practice setting

Bilingual (English/Spanish) preferred.

Skills

• Confident, autonomous, solution-driven, detail-oriented, with high standards of excellence
• Nonjudgmental, diplomatic, resourceful, intuitive, dedicated, resilient, and proactive
• Strong verbal and written communication skills, including motivational coaching, influencing, and negotiation abilities
• Strong time management and organizational skills
• Strong problem-solving skills
• Ability to prioritize and manage changing priorities under pressure

Schedule

9:00 AM - 5:00 PM