Job Description

Job Summary:
Permanent Supportive Housing (PSH) is a model that combines low-barrier, affordable housing, health care, and supportive services to help individuals and families achieve and maintain housing stability. PSH typically serves individuals who are experiencing homelessness or housing instability, face multiple barriers to housing, and require supportive services to maintain long-term stability.
Under the direction of the Manager, Permanent Supportive Housing, the Case Manager contributes to the PSH Care Team by providing strength-based case management services to individuals with a history of chronic homelessness, behavioral health conditions, and other psychosocial needs. This role promotes wellness, housing stability, and housing retention through integrated care coordination, service planning, supportive interventions, and linkage to internal and external resources that address whole-person health needs, including medical care, behavioral health care, substance use services, and social determinants of health.
Essential Duties and Responsibilities:
• Engagement, Assessment, and Client Support
◦ Explain the purpose, expectations, and process of case management services to clients and support informed participation in services.
◦ Obtain relevant information from clients and collateral sources to assess strengths, needs, preferences, safety, well-being, activities of daily living, instrumental activities of daily living, and immediate service needs.
◦ Administer appropriate screening and assessment tools to support shared decision-making, goal setting, and individualized service planning.
◦ Establish and maintain positive, therapeutic relationships with clients through face-to-face, telephonic, office-based, property-based, and community-based engagement.
◦ Engage clients through assertive outreach to identify wellness needs, service preferences, barriers, and opportunities for support.
◦ Support clients in developing independent living skills, including budgeting, paying bills, understanding leases, and maintaining housing stability.
• Service Planning, Case Management, and Housing Stability
◦ Review assessment and screening outcomes with clients to prioritize needs and develop immediate, short-term, and long-term service goals.
◦ Develop and maintain individualized service plans and housing success plans that reflect client strengths, needs, measurable goals, timeframes, and case management strategies.
◦ Provide individualized case management, care coordination, and Therapeutic Behavioral Services in settings that meet the needs of the client.
◦ Provide behavioral health interventions based on client presentation, assessed needs, preferences, medical necessity, and applicable evidence-based practices.
◦ Apply Housing First, Harm Reduction, Motivational Interviewing, Stages of Change, Stage-Wise Interventions, and other evidence-based approaches to support wellness and housing stability.
◦ Provide ongoing pro-social support and life skills training on an individual and group basis to promote independence, wellness, and housing retention.
◦ Conduct ongoing monitoring to assess progress, evaluate the effectiveness of service plan strategies, and adjust interventions as needed.
◦ Appropriately transition or terminate case management services, including providing reasonable notice and supporting continuity of care when applicable.
• Coordination, Linkage, and Monitoring
◦ Work collaboratively with the multidisciplinary service team, including counselors, nurses, physicians, pharmacists, social service staff, Property Management, and the PSH Care Team to support positive client outcomes.
◦ Identify, maintain, and use knowledge of community resources to connect clients with supports related to housing, neighborhood and environmental needs, social supports, peer and community needs, economic needs, education, vocational goals, and other social determinants of health.
◦ Make formal and informal referrals to service providers identified in the case management plan and follow up to address barriers to care, resources, and services.
◦ Support clients following hospitalization or other transitions in care to promote community functioning and reduce avoidable emergency room or hospital utilization when possible.
◦ Assist clients with linkage to primary care, behavioral health, substance use, and other needed services, including attending appointments, transporting or accompanying clients, and addressing transportation barriers as needed.
◦ Identify and address barriers to medication adherence, medical appointments, behavioral health appointments, benefit access, and service engagement.
◦ Assist clients with benefit applications, renewals, advocacy, and appeal processes as needed.
◦ Participate in multidisciplinary team meetings, Property Management meetings, PSH Team meetings, PSH application interviews, move-in activities, routine housing inspections, and move-out planning.
◦ Facilitate team-based care by supporting communication among clients, healthcare teams, service providers, property management, and client support networks.
◦ Develop and participate in community-building activities in collaboration with the PSH Care Team, which may include tenant associations, orientation supports, newsletters, welcoming activities, support groups, or other social and community-oriented programming.
• Clinical Proficiency, Documentation, and Compliance
◦ Recognize common behavioral health, physical health, and substance misuse conditions and symptoms, and apply prevention measures to mitigate potential behavioral health crises.
◦ Understand and apply risk assessment practices, including crisis and lethality assessment, and use clinical supervision appropriately.
◦ Use the organization’s electronic medical record system to document case management service activity, progress, outcomes, consents, and related information in a clear, concise, objective, professional, and timely manner.
◦ Ensure documentation clearly links services provided to the client’s service plan, goals, progress, and outcomes.
◦ Protect client privacy and confidentiality in accordance with applicable laws, regulations, organizational policies, and best practices, including obtaining or confirming appropriate releases before sharing client information.
◦ Ensure required consents to services are completed, signed, dated, and on file before providing treatment or services.
◦ Follow applicable professional codes of ethics, standards of practice, federal and state requirements, and organizational policies to protect client rights and promote quality care.
◦ Prepare reports and utilize available data to support positive client health outcomes and program needs.
• Site and Program Support
◦ Support onsite food pantry operations approximately once per month, including inventory, shopping, pickup and/or coordination of delivery, and related duties as assigned.
◦ Obtain and maintain required food safety certification, as applicable and provided through The Centers.
◦ Maintain supply inventory at assigned site.
Other Non-Essential Duties and Responsibilities:
• Perform other related duties as assigned.
Qualifications:
Education:
• High school diploma or equivalent
• Bachelor’s degree in Social Work, Psychology, or a mental health-related field preferred. If degree is in a related field, two years of care coordination or case management experience is preferred.
Licensure/Certification:
• Valid Ohio driver’s license and access to an insured vehicle required for client transportation and community-based services.
• Nonviolent Crisis Intervention certification required within 60 days of hire.
• Active Community Health Worker certification preferred.

Experience:
• At least three years of case management or care coordination experience required.
• Prior experience working with adults with serious and persistent mental illness preferred.
Skills:
• Ability to work collaboratively and effectively as part of a multidisciplinary team.
• Ability to develop effective therapeutic relationships and engage clients in assessment, goal setting, service planning, and ongoing care coordination.
• Ability to identify needs, problem-solve barriers, and connect clients to appropriate community resources and supports.
• Working knowledge of behavioral health, substance use, trauma-informed care, stages of change, harm reduction, and housing stability practices.
• Ability to understand and support the agency’s team-based service delivery model, program philosophy, and client-centered approach.
Working Conditions:
This role operates in a professional office, program, property-based, and community-based environment. The employee routinely uses standard office equipment and technology to complete documentation, communicate with clients and service providers, and support program operations. While performing the duties of this position, the employee is regularly required to communicate verbally and in writing, listen effectively, sit for extended periods, stand, walk, use hands and fingers, and reach with hands and arms. Local travel within the Cleveland area and surrounding communities is required to provide case management services, attend meetings and trainings, transport or accompany clients, and support community-based service needs. The employee may be required to lift up to 40 pounds occasionally in connection with site, delivery, or food pantry activities. The employee is expected to use approved nonviolent crisis intervention and de-escalation techniques when needed.