Job Description

Job Description

Job Description

JOB TITLE: Case Manager/Service Coordinator

PROGRAM: Safe Options Support (SOS) Team

REPORTS TO: Team Leader

SHIFT: 1:00pm-9:00pm; availability to work one weekend day (Saturday or Sunday)

Job summary:

An excellent opportunity for an experienced Case Manager to play a pivotal role on one the Governor’s offices newly launched innovative Safe Options Support (SOS) team that that will provide comprehensive care to street homeless or subway dwelling individuals.

The multi-disciplinary SOS team will consist of a Team leader, Licensed Clinicians, Care Managers, a Registered Nurse, and a Peer. The team will support program participants in the community through the application of the highly acclaimed, Critical Time Intervention (CTI), evidence-based, model of care.

The Case Manager’s role will involve community outreach on the streets and subways, coordinating participants needs before and after their move from street to home, enhancing their daily living skills, accompaniment to appointments, and advocating on their behalf when faced with discrimination or healthcare inequities. Member choice, harm reduction, non-coercion, flexibility, and person-centered care are essential elements of the SOS program model and should be front and center of the care delivered by the Case Manager

The SOS teams will continue to follow participants for several months after housing placement to ensure their stability, independence, and wellbeing in their new community. The role will require field-based work, periodic on call coverage, and a willingness to work flexible hours. On job training will be provided around CTI and regular learning collaboratives will be available to enhance the Case Manager’s professional development.

This is an exciting opportunity for a Case Manager who is looking to transform community healthcare in NYC and making long lasting, positive changes in the lives of homeless New Yorkers.

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). Case Management work experience in a social service agency, preferable serving a behavioral health population. Four years of past work case management work experience may be considered in lieu of Bachelor’s degree. Bilingual in Spanish preferred.

Job Responsibilities:

• Persistent and assertive outreach and engagement using strength-based approaches beginning either at known “hang-outs” or “Hot spots” within the transit system or during an inpatient hospital admission or emergency department visit.
• Continuously assess the health and social needs of participants through SOS’s conversational and observational assessments and formalized risk assessments tools for those identified as being at high risk.
• Work in collaborations with the centralized SOR Hub to identify available housing and to support participants through the process. Tasks may include completing HRA 2010e, applying for housing, prepping for interviews, follow up with housing providers, and assistance with moving in (day of move) with obtaining housing supplies and learning the neighborhood.
• Participate in hospital discharge planning meetings to identify the best community resources for returning patients.
• Collects and reports data, as required and work with team leader, data analyst and other SOS teams to use data to inform future care delivery.
• Once housed work with participants and their housing providers to resolve clinical issues that are impacting on the participant’s ability manage and retain supportive housing.
• Foster relationship with community provides to ensure that recipients are connected with appropriate services as they transition back into the community.
• Appointment navigation including accompaniment to appointments, travel training, reengagement in community care, and addressing barriers to care.
• Review documentation and conduct comprehensive psychosocial assessments to determine the medical, psychiatric, housing and other social needs in the community.
• Obtain historical and collateral information from multiple sources to support participants behavioral and physical health needs.
• Monitor, evaluate and record participants progress with respect to care plan goals.
• Attend and participate in team meetings and supervisory sessions.
• Perform other related duties as assigned.

Essential Knowledge, Skills and Abilities:

• Experience working with homeless and/or precariously housed populations preferred but not required.
• Knowledge of homeless resources, NYC shelter systems, and MTA transit systems a plus.
• Knowledge of counseling principles and methods for mental illness and substance use disorders.
• Knowledge of treatment, rehabilitation, and community support programs as they relate to recipient/residents, families, and staff.
• Ability to develop, evaluate, implement, and modify treatment intervention to meet the needs of individual recipients.
• Ability to prepare accurate and timely reports.
• Computer proficiency and good documentation skills.

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.

Salary : $60,000 plus generous benefits

ACMH is committed to the mental and physical wellbeing of vulnerable New Yorkers and is a leader in the provision of outreach and engagement, care management, rehabilitation, crisis support, and supportive housing. ACMH is committed to becoming an anti-racist organization and seeks to promote actionable change to create an intentional culture of equity at individual, interpersonal and institutional levels.

ACMH is an equal opportunity employer and does not discriminate in employment decisions based on race, color, creed, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, mental or physical disability, marital status, veteran status or citizenship status.

For more information, visit our website:

ACMH is committed to the mental and physical wellbeing of vulnerable New Yorkers and is a leader in the provision of outreach and engagement, care management, rehabilitation, crisis support, and supportive housing. ACMH is committed to becoming an anti-racist organization and seeks to promote actionable change to create an intentional culture of equity at individual, interpersonal and institutional levels.
For more information, visit our website:

Company Description

ACMH is committed to the mental and physical wellbeing of vulnerable New Yorkers and is a leader in the provision of outreach and engagement, care management, rehabilitation, crisis support, and supportive housing. ACMH is committed to becoming an anti-racist organization and seeks to promote actionable change to create an intentional culture of equity at individual, interpersonal and institutional levels.\r\nFor more information, visit our website:

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