Care Manager (Pathway Home - MTA)

Scope of Position

Program Description: Field-based innovative care transition team that serves individuals identified by New York State Office of Mental Health (OMH) and the New York State Office of Temporary and Disability Assistance (OTDA) as long-term homeless, living or having lived in the subway system, with behavioral health and medical conditions.

Job summary:  Experienced Case Manager to work on a newly funded field-based innovative care transition team that serves individuals identified by New York State Office of Mental Health (OMH) and the New York State Office of Temporary and Disability Assistance (OTDA) as long-term homeless with behavioral health and medical conditions. The team will follow individuals into the community using the Pathway Home™ model of care to ensure that they become both linked and engaged with identified community providers and that their support network is sufficient to meet their needs. The role will involve facilitating transition from one level of care to the community by addressing the preparatory needs of participants in the early stages of recovery, discharge planning, development of daily living skills, and coping mechanisms through group and individual work in the community. The team will follow participants into the community using the Pathway Home™ model of care to ensure that they become both linked and engaged with identified community providers and that their support network is sufficient to meet their needs. The role will require on call coverage and a willingness to work flexible hours.

Job Responsibilities:

• Engagement with NYC homeless individuals beginning either at known “hang-outs” or during an inpatient hospital admission or emergency department visit with involvement in transition planning, including a needs assessment of community transition supports essential to stabilizing the participant;
• Individual sessions with participants emphasizing prevention and preparing for independent community living and the promotion of optimum mental and emotional health. May require helping participants deal with issues associated with but not limited to family and social relationships; stress and symptom management; activities of daily living; medication management; and housing readiness;
• Work with participants and their housing providers to resolve clinical issues that are impacting on the participant’s ability to obtain, manage, and retain supportive housing;
• Foster connection and engagement with community based organizations that promote a sense of purpose, physical wellness, education, employment, socialization, and community involvement;
• Community navigation including accompanying to first behavioral health and medical appointment, travel training, reengagement in community care, referral to services with ability to identify and address potential services and barriers to obtain and maintain such services;
• Establish collaborative working relationships with referring treatment teams and other partners and plan with them for appropriate discharges for participants;
• Provide intensive emotional and practical support to participants as they transition back into their communities;
• Provide on-call after hour crisis intervention services when needed to participants and their support network, including respite referrals and other diversion and stabilization services;
• Attend and participate in team meetings and supervisory sessions;
• Review documentation and conduct comprehensive psychosocial assessments to determine the medical, psychiatric, housing and other social needs in the community;
• Develop short-term person-centered care plans to assist participant towards achieving their goals;
• Monitor and record participant’s progress and modify plan according to needs and preferences;
• Timely and accurate documentation of participant information within Health Information Technology platform
• Assist and instruct Participants in attending to daily living skills such as personal hygiene, grooming and laundry, nutrition/meal preparation, budgeting, and socialization tasks and skills needed to successfully live and work in the community environments of their choice and also in maintaining a safe living environment;
• Comply with all required in-service training and staff development;
• Perform other related duties as assigned;

Education/Qualifications:

Minimum Education and Experience Requirements:  Bachelor’s degree or higher, preferable in psychology, social work, sociology, or related field or be a New York State Licensed Practical Nurse (LPN).  2 years of case management work experience in a social service agency, preferable serving a behavioral health population. Knowledge of mental illness and the needs of individual living with severe and persistent mental illness. Demonstrated competency in written, verbal and computational skills to present and document records in accordance with program standards.

Essential Knowledge, Skills and Abilities:

• Knowledge of mental illness, behavioral health legislation and regulations, and health conditions
• Knowledge of homeless resources, NYC shelter systems, and MTA transit systems.
• Experience working with homeless and precariously housed populations.
• Ability to manage multiple projects and ask for help when needed
• Ability to participate on a team to accomplish tasks
• Serves as a role model to staff and stakeholders
• Ability to work with all stakeholders: members, network, families, and government staff in a caring and respectful manner, and with due understanding of and consideration for cultural differences
• Available to work a flexible schedule in response to participant needs.
• Computer proficiency in Microsoft applications such as MS Word, Excel, PowerPoint.
• Knowledge of treatment, rehabilitation, and community support programs as they relate to recipients and their families
• Knowledge of health and community support programs and systems
• Knowledge of techniques for identifying risk, including crisis management techniques

This job description in no way states or implies that these are the only job related duties to be performed by the employee. You will be required to follow any other job-related instructions and perform any other job-related duties requested by your supervisor.

This position requires travel throughout the five boroughs of New York City. 

The Bridge is an AA/EOE

COVID-19 VACCINATION REQUIRED

MASK WEARING REQUIRED

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