Job Description

Overview

Central Health’s High Risk Populations Department provides innovative, patient-centered care to individuals experiencing homelessness and housing instability. These programs address gaps in medical care by combining access to health services with intensive case management, emergency shelter support, and coordination of social services. This role will be expected to support one or more programs including The Bridge Program, Medical Respite, Housing Support Program, and more.

The Bridge Program includes a short term, transitional clinic designed to bridge gaps in care for individuals who lack consistent access to primary or specialty medical services. Operating out of Central Health’s Capital Plaza location and through mobile outreach sites, the Bridge Program provides low-barrier medical care and intensive case management for patients experiencing homelessness or housing instability. The program focuses on stabilization, engagement, and connection to a long-term medical home, ensuring continuity of care while addressing immediate health and social needs.

The Medical Respite Program provides a safe, temporary place for individuals experiencing homelessness to recover from acute illness, injury, or hospitalization while receiving ongoing medical oversight and case management support. Medical Respite offers access to emergency shelter, coordinated medical and behavioral health services, and daily engagement from a multidisciplinary care team. During their stay, participants are supported in improving their health while also addressing critical social needs such as housing placement, benefits enrollment, and linkage to community resources to promote long-term stability.

The Housing Support Program supports individuals in their transition into stable housing by providing intensive case management support with the goal of housing independence. Case Manager will be expected to perform move-in readiness, home visits, and providing skills training.

The Case Manager is a key member of a multidisciplinary team, providing intensive, trauma-informed case management to patients served through Bridge, Medical Respite, and Housing Support Programs. Case Managers are skilled in crisis management and advocacy, providing timely referrals to appropriate services while supporting patients in accessing benefits and entitlements and identifying safe, affordable housing. This role works across fixed clinic sites, mobile locations, and respite setting to promote improved health outcomes, stability, and selfsufficiency as part of a comprehensive approach to ending homelessness.

Responsibilities

Essential Functions:

• Conduct whole-person assessments to determine client’s strengths, barriers, mental health needs, and readiness to change
• Provides crisis intervention services (assessment, evaluation of risk, safety planning, referral, and follow up)
• Develops individualized care plans in collaboration with patients, that address mental health, medical, and social determinants of health
• Effectively de-escalate heightened situations with patients experiencing trauma, exacerbated mental health symptoms, and behavioral complexity while using a trauma informed care approach
• Provides goal oriented and solution focused services and evidenced based interventions to address mental health and psychosocial needs
• Educates and works collaboratively with patients on available community resources while advocating and helping to coordinate with community supports and services
• Teaches patients through structure and modeling appropriate expectations and guide them on following through with their tasks
• Helps patients identify and manage challenges or barriers in navigating their health and government benefits
• Accompany patients to appointments as needed
• Assists patients directly or indirectly with housing survey (Coordinated Assessment)
• Works with patients on discharge planning by reviewing potential transitional housing programs, assisting with room rental search, and applications for housing units
• Collaborate with housing specialists and/or other resources to identify and address psychological, social and medical needs, and coordinates referrals for housing programs
• Works collaboratively and advocates with patient’s interdisciplinary team, community resources, and partner agencies
• Participates in interdisciplinary case conference to support coordinated patient care
• Assists other teams within the department as needed
• Completes documentation in a timely manner
• Other duties as assigned

Knowledge, Skills and Abilities:

• High level of skill at building relationships and providing excellent patient support
• High level of problem-solving skills to better serve patients and staff
• Strong attention to detail and accuracy
• Excellent verbal and written communication skills
• Demonstrated knowledge of community resources available and how to access resources for the benefit of clients
• Demonstrated success in collaborating with multidisciplinary team members
• Bilingual (Spanish/English) preferred
• Strong knowledge of evidenced based practices commonly used in case management, crisis intervention, and the populations served
• Strong Knowledge of mental health and substance use diagnoses, trauma informed care, patient engagement, motivational interviewing, and cultural competency

Qualifications

Required Education:

• Bachelor's degree in Social Work or related field (higher degree accepted)

Required Experience (Less than 1 year):

• Internship or work in field related to social work, case management, or counseling individuals in crisis/trauma situations.
• Demonstate knowledge of community resources available and how to access resources for the benefit of clients

Required Licenses and Certifications:

• Valid driver's license
• Basic Life Support