Job Description

• Weekly work schedule: Monday – Friday
• Hours: 8 am to 4:30 pm
• Experience: Working with people experiencing homelessness (strongly preferred)

• Conduct comprehensive assessments of patients' medical, social, and psychological needs.
• Conduct face to face visits to clients in facilities to complete initial housing acuity index assessments and develop individualized care plans 90 days in collaboration with the patient, healthcare team, and other relevant parties.
• Provide weekly case management and coordinate services and supports according to the established care plan during the first 90 days of move into facility, including but not limited to the following:
• Provide bi-weekly case management services to clients who have been in the facility for 4-6 months.
• Utilizes environmental data gathered in relation to the medical or mental health problems to make recommendations concerning the provision of services that will ensure maximum benefits for each patient.
• Coordinate and monitor the implementation of the care plan, ensuring timely access to necessary medical services.
• Regularly evaluate and update the care plan based on the patient's progress and changing needs.
• Maintain accurate and up-to-date documentation of client assessments, care plans, interventions, and progress.
• Coordinate with insurance providers, public agencies, and community organizations to advocate for clients' access to necessary resources and services.
• Comply with legal and ethical guidelines regarding client confidentiality and information security.
• Advocate for clients’ rights and assist in resolving any barriers to accessing healthcare services.
• Educate clients about their living conditions and self-care techniques.
• Assist clients in understanding and adhering to prescribed medication regimens and healthcare recommendations.
• Offer information and referrals to relevant community resources and support services.
• Collaborate with healthcare professionals, social workers, and other stakeholders to ensure effective communication and coordination of care.
• Facilitate communication between the client, facility operator and the healthcare team, ensuring that all parties are well-informed and involved in decision-making.
• Attend interdisciplinary meetings and contribute insights regarding clients' medical and psychosocial needs.
• Prepare reports summarizing client' medical and social situations, highlighting any significant changes or concerns.
• Makes referrals to and works with various public and private health, mental health or other agencies such as the Department of Public Social Services, Legal Aid, Public Health Department, Free Clinics, to resolve client's personal and social problems. Other Skills, Knowledge, and Abilities
• Homeless health care experience.
• Experience with delivering clinical care services within ARFs and RCFEs.
• Familiarity with complex care management services for the care of high-need/high-cost Medical beneficiaries.
• Ability to lead teams in performance improvement activities.
• Demonstrated teaching and communication skills with non-clinical and clinical staff.
• Experience/expertise in assessing and managing clients with dysfunctional substance use disorder (SUD), including knowledge of MAT (Medication-Assisted Treatment) and Addiction Psychiatry.
• Experience/expertise in assessing and managing clients with serious persistent mental illness.
• Experience/expertise in trauma-informed care and harm reduction principles.
• Familiarity with DMH, DPH and community mental health and substance use programs and resources.