Case Manager​/Service Coordinator - Safe Options Support (SOS) Team

Job Description

JOB TITLE:
Case Manager/Service Coordinator

PROGRAM:
Safe Options Support (SOS) Team

REPORTS TO:
Team Leader

SHIFT:
Tuesday through Saturday, 9:00am-5:00pm

Job summary:

An excellent opportunity for an experienced Case Manager to play a pivotal role on the Governor’s office’s newly launched Safe Options Support (SOS) team that will provide comprehensive care to street homeless or subway‑dwelling individuals. The multi‑disciplinary SOS team will consist of a Team Leader, Licensed Clinicians, Care Managers, a Registered Nurse, and a Peer. The team will support program participants in the community through the application of the highly acclaimed Critical Time Intervention (CTI) evidence‑based model of care.

The Case Manager’s role involves community outreach on the streets and subways, coordinating participants’ needs before and after their move from street to home, enhancing their daily living skills, accompanying them to appointments, and advocating on their behalf when faced with discrimination or healthcare inequities. Member choice, harm reduction, non‑coercion, flexibility, and person‑centered care are essential elements of the SOS program model that should be front and center of the care delivered by the Case Manager.

The SOS teams will continue to follow participants for several months after housing placement to ensure their stability, independence, and wellbeing in their new community. The role requires field‑based work, periodic on‑call coverage, and a willingness to work flexible hours. On‑job training will be provided around CTI and regular learning collaboratives will be available to enhance the Case Manager’s professional development.

Minimum

Education and Experience Requirements:

Bachelor’s degree or higher, preferably in psychology, social work, sociology, or a related field, or be a New York State Licensed Practical Nurse (LPN). Case Management work experience in a social service agency, preferably serving a behavioral health population. Four years of past case management work experience may be considered in lieu of a Bachelor’s degree. Bilingual in Spanish preferred.

• Persistent and assertive outreach and engagement using strength‑based approaches beginning 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 assisting with moving in (day of move) with obtaining housing supplies and learning the neighborhood.
• Participate in hospital discharge planning meetings to identify the best community resources for returning patients.
• Collect and report data, as required, and work with the team leader, data analyst 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 the participant’s ability to manage and retain supportive housing.
• Foster relationships with community providers to ensure that recipients are connected with appropriate services as they transition back into the community.
• Appointment navigation including accompaniment to appointments, travel training, re‑engagement 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 participants’ behavioral and physical health needs.
• Monitor, evaluate and record participants’ progress with respect to care plan goals.
• Attend and participate in team meetings and supervisory sessions.
• Perform other related duties as assigned.