Sr. Case Manager - Full-time; 4411-605-N

For over 125 years, Catholic Charities Brooklyn and Queens has been providing quality social services to the neighborhoods of Brooklyn and Queens, and currently offers 160-plus programs and services for children, youth, adults, seniors, and those struggling with mental illness. Kingsborough Transitional Team and Kingsborough Transition Team provide intensive wraparound services for the severely chronically mentally ill who have a history of recent psychiatric hospitalization. This critical time intervention is provided for a duration of 6 to 9 months. Service includes coordination of psychiatric and medical care, community access to services, as well as connections to housing services, counseling, nursing and medication management.

STATEMENT OF THE JOB

This is a direct care position assigned to the Pathway Home transition team in Brooklyn, embedded at Kingsborough State Psychiatric Center. The Sr. Case Manager will work on a newly funded field-based innovative Care Transition team that serves individuals transitioning to the community from a higher level of care. As a member of the Pathway Home™ multi-disciplinary team, the Sr. Case Manager will work under the supervision of the Team Leader. The role will involve facilitating transition from one level of care to the community by addressing the preparatory needs of participants in the early stages of recovery, discharge planning, development of daily living skills, and coping mechanisms through group and individual work in the community. The team will follow participants into the community using the Pathway Home™ model of care to ensure that they become both linked and engaged with identified community providers and that their support network is sufficient to meet their needs. The role will require on call coverage and a willingness to work flexible hours.

DUTIES AND RESPONSIBILITIES

Engage in-patient clients at acute care hospitals, state psychiatric centers or state operated residences and participate in the coordination of their discharge; beginning from referring location with involvement in transition planning, including a needs assessment of community transition supports essential to stabilizing the client. Provide intensive emotional and practical support to clients as they transition back into their communities. Conduct home visits as assigned. Accompany clients to appointments with community-based treatment providers and other services as needed. Individual sessions with clients emphasizing prevention and preparing for independent community living and the promotion of optimum mental and emotional health. May require helping clients deal with issues associated with but not limited to family and social relationships; stress and symptom management; activities of daily living; medication management; and housing readiness. Work with clients and their housing providers to resolve clinical issues that are impacting on the participant’s ability to obtain, manage, and retain supportive housing. Foster connection and engagement with community-based organizations that promote a sense of purpose, physical wellness, education, employment, socialization, and community involvement. Community navigation including accompanying clients to first behavioral health and medical appointment, travel training, reengagement in community care, referral to services with ability to identify and address potential services and barriers to obtain and maintain such services. Establish collaborative working relationships with referring treatment teams and other partners and plan with them for appropriate discharges for clients. Review documentation and conduct comprehensive psychosocial assessments to determine the medical, psychiatric, housing and other social needs in the community. Develop short-term, person-centered care plans to assist client towards achieving their goals. Monitor and record client’s progress and modify care plan according to needs and preferences. Assist and instruct clients in attending to daily living skills such as personal hygiene, grooming and laundry, nutrition/meal preparation, budgeting, and socialization tasks and skills needed to successfully live and work in the community environments of their choice and in maintaining a safe living environment. Support clients in sustaining community tenure by ensuring strong linkage to community-based treatment programs and resources. Provide on-call after hour crisis intervention services when needed to clients and their support network, including respite referrals and other diversion and stabilization services. Responsible for timely and accurate documentation of client information within Health Information Technology platform(s). Responsible for meeting monthly service delivery metrics, health outcomes metrics and billing requirements for HH+ clients. Attend and participate in team meetings and supervisory sessions. Comply with all required in-service training and staff development. SPECIFICATIONS FOR EDUCATION/CERTIFICATIONS/LICENSES Bachelor’s degree, preferable in psychology, social work, sociology. New York State Licensed Practical Nurse (LPN) may be substituted for the Bachelor’s degree.

SPECIFICATIONS FOR EXPERIENCE AND TRAINING

Case management work experience in a social service agency, preferable serving a mental health population. Knowledge of mental illness and the needs of individuals living with severe and persistent mental illness. Knowledge of substance abuse disorders, physical health conditions, and behavioral health legislation and regulations. Knowledge of treatment, rehabilitation, and community support programs as they relate to consumers/residents, families, and staff. Knowledge of techniques for identifying and preventing potentially violent behavior, including crisis management techniques. Ability to develop, evaluate, implement and modify a clinical treatment intervention to meet the needs of individual clients. Ability to manage multiple projects and ask for help when needed- strong organizational and time management skills. Ability to participate on a team to accomplish tasks. Ability to work with all stakeholders: members, network, families, and government staff in a caring and respectful manner, and with due understanding of and consideration for cultural differences. Serves as a role model to staff and stakeholders. Available to work a flexible schedule in response to client needs. Ability to prepare accurate and timely reports. Strong oral and written communication abilities. Computer proficiency in Microsoft applications such as MS Word, Excel, PowerPoint.

SPECIFICATIONS FOR PHYSICAL REQUIREMENTS

Must be able to share staff rotation for emergency on-call and office coverage. Regularly required to talk, hear, walk, stand & sit. Able to lift up to 10 pounds. Able to climb stairs and make home visits. Able to stretch and bend to retrieve files. Able to operate a computer keyboard, mouse, & office equipment. Able to read printed materials and computer screens. Able to write. Able to sit and work on the computer for long periods of time. Able to travel to multiple locations as needed.

BENEFITS

We offer competitive salary and excellent benefits including: Generous time off (Vacation/ Personal Days/ Sick Days/ Paid Holidays annually) Medical, Dental Vision Retirement Savings with Agency Match Transit Flexible Spending Account Life insurancePublic Loan Forgiveness Qualified Employer Training Series and other additional voluntary benefits. For more information on our organization, please visit our website at:

EOE/AA.

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