Reentry Health Home Plus Care Manager

Compensation Range: $60,000/year

Spanish bilingual proficiency is preferred for this role. Candidates hired to support clients in Spanish are eligible for additional compensation.   

Overview: 

The HH+ Case Manager works with members and the member’s network of providers to help minimize barriers to care and help members achieve improved health outcomes. Using interventions such as care coordination, motivational interviewing and health promotion. HH+ Case Managers help members, over the course of time, develop the skills needed to manage their health and psychosocial needs with greater independence. HH+ Case Managers will have the opportunity to work as part of outcome driven integrated team and participate in agency-wide quality improvement activities aimed at improving the delivery of care to individuals living with chronic illness, behavioral health issues, and homelessness.   

To ensure high-quality, person-centered care, Care Managers are expected to maintain an active and consistent field and office presence. Meaningful face-to-face interaction with clients and service providers is an essential, and required, component of this role and is critical to fostering engagement, coordinating care, and achieving positive health outcomes.  

At Housing Works, we believe our staff are one of our greatest assets. We demonstrate this commitment by offering a competitive salary, generous tuition reimbursement, and a robust benefits package, including opportunities for eligible team members to further their education and professional growth.

Responsibilities:  

The HH+ Care Manager guides clients with chronic illness(es) and those with prior justice involvement through the health care system through direct, in-person engagement, hands-on care coordination, and ongoing relationship-building with clients and service providers. This role focuses on reducing barriers to care, strengthening client participation in services, and tracking interventions and outcomes to support long-term stability and improved health outcomes. 

• Conduct comprehensive in-person initial assessments and annual reassessments of clients’ medical, mental health, substance use, financial, housing, and support needs in community, home, clinical, or office-based settings. 
• Manage a caseload of 20 clients with high level of care needs.  
• Develop and maintain individualized, patient-centered plans of care with documented input and approval from clients and collaborating providers, updating care plans at least every 3–6 months or when new needs are identified, in accordance with Health Home standards. 
• Collaborate closely with medical and behavioral health providers through face-to-face meetings and coordinated care activities to develop, implement, and monitor care plans for clients with chronic conditions such as diabetes, asthma, congestive heart failure, hypertension, behavioral health conditions, HIV, and other complex health needs. 
• Engage clients in person to review housing options based on program eligibility and provide hands-on assistance with housing-related applications, including the 2010E (application submission and psychosocial completion), NYC Housing Connect, Section 8, and other relevant housing programs.  The CM may also prepare and go with clients on apartment viewings, advocate with housing providers and landlords, research and provide housing resources to clients. 
• Address benefits-related needs through direct client support, including Medicaid, HRA, SNAP benefits, medical transportation, and other entitlement programs, utilizing in-person advocacy and coordination when appropriate. 
• Conduct regular home and field visits to maintain consistent client engagement, assess changing needs, and support progress toward care plan goals in accordance with Health Home program standards and client preferences. 
• Coordinate client services with internal and external providers through regular, in-person or hybrid case conferencing, occurring at least quarterly, to ensure alignment, accountability, and continuity of care. 
• Document all in-person and care coordination activities, client outcomes, and care plan progress in the case record, ensuring timely and accurate documentation for the full caseload. 
•  Maintain strict confidentiality in all client interactions and records. 
• Perform other duties as assigned.

Qualifications/Requirements:  

• Adept with word processing, Excel, and Microsoft Office products; Previous experience with Electronic Health Records a plus 
• Ability to communicate well both written and oral 
• Good organizational and multi-tasking skills  
• Positive attitude and adaptable with both staff and clients 
• Highly organized with the ability to work independently and prioritize multiple responsibilities in a fast-paced environment 
• Comfortable working with a diverse group of staff and clients

The following additional competencies are viewed as important to success in this position:  

• Proficiency and comfort with online meeting software such as Zoom and Microsoft Teams 
• Understanding of chronic medical conditions, homelessness, substance use and mental illness 
• Knowledge of City, State, and Federal entitlement and benefit systems. 

Essential Physical Demands/Working Conditions: 

• Ability to travel within the boroughs via public transportation and ability to work from remote office locations. 
• Requires access to email, phone, Zoom and Teams. 
• Requires ability to comply with agency confidentiality guidelines in remote workspace   

Housing Works 

Housing Works was founded in 1990 with a long-term commitment to AIDS advocacy. Housing Works established New York State’s first harm reduction-based, OASAS-licensed outpatient drug treatment program. Other services include Health Home care management, behavioral health, and syringe exchange programs. 

A pioneer in the social entrepreneurship movement, Housing Works operates 10 high-end thrift shops in Manhattan and Brooklyn and a much-loved Bookstore Cafe in Soho. Housing Works fights for funding and legislation to ensure that all people living with HIV/AIDS have access to quality housing, healthcare, HIV prevention, and treatment, among other lifesaving services. For more information, visit www.housingworks.org.

Important Information for Applicants 

• COVID-19 Vaccination Requirement: Housing Works requires employees working in our Health Services division to be fully vaccinated against COVID-19, unless approved for a legal accommodation. If you need an accommodation for any reason, including related to this job requirement, please contact Human Resources.

• Fraud Alert: Job candidates should be aware that scammers may pose as employers and create fake job postings in order to extract personal information from individuals for financial gain. Housing Works will never ask job candidates for personal information, such as social security numbers or bank account details, over the phone. If you suspect that a job posting may be fake or wish to confirm that a job posting from Housing Works is genuine, please contact us at recruitment@housingworks.org.

   

Benefits 

• We have three comprehensive healthcare plans to choose from based on your priorities and budget. Housing Works covers most of the plan; you pay a portion, based on your salary.

• Staff begins accruing PTO immediately for a total of up to 30 days earned in the first year.

• We offer employees an educational benefit. This money is available for tuition loan reimbursement, tuition costs, and textbooks.

   

Equal Employment Opportunity 

Housing Works provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Housing Works complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. Housing Works also does not request prior salary information during the hiring process. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

This position is included in a bargaining unit of Housing Works’ New York City employees represented by a labor union known as the Retail Wholesale and Department Store Union (“RWDSU”). Accordingly, the RWDSU has the exclusive right to bargain over the terms and conditions of employment related to this position and this position may become covered by the terms of a collective bargaining agreement (a “CBA”) between Housing Works and the RWDSU