Health Home Plus (HH+) Care Coordinator - Brooklyn/Queens

Health Home Plus (HH+) Care ManagerBe the Bridge. Empower Lives. Thrive with Support.Are you driven to help individuals with complex health needs navigate life's most critical transitions? Do you excel when you're out in the community — meeting clients where they are and guiding them toward stability? We're seeking passionate HH+ Care Managers who specialize in transitions of care, with a readiness to be in the field and make real, face-to-face impact.Your Mission: Guide Clients Through Critical TransitionsAs a Health Home Plus Care Manager, you'll work with individuals living with serious mental illness and chronic conditions, helping them move safely from hospital to home, inpatient care to community support, or detox to ongoing treatment. Extensive fieldwork is at the heart of this role — you'll be on the ground, advocating, coordinating, and walking alongside your clients at every step.What You'll DoCoordinate safe, smooth transitions from hospitals, detox/rehab centers, and psychiatric inpatient facilitiesConduct frequent field visits to client homes, shelters, hospitals, and community agenciesDevelop and manage comprehensive, individualized care plans addressing medical, behavioral, and social needsCollaborate closely with providers, discharge planners, and community partners to ensure continuity of careConnect clients with housing, benefits, outpatient treatment, peer supports, and other vital servicesMonitor risk factors, ensure follow-ups, and advocate fiercely for each client's stability and wellnessSupport clients in navigating complex healthcare and social systems with compassion and clarityWhat You'll BringBachelor's degree in Social Work, Nursing, Psychology, or a related human services field (Master's/licensure is a plus!)At least two (2) years working with individuals with serious mental illness, co-occurring disorders, or chronic conditionsStrong background in care transitions, discharge planning, community outreach, or case managementA self-starter who is comfortable with extensive fieldwork and building community relationshipsExcellent communication, organization, and problem-solving skillsCommitment to trauma-informed, person-centered careWhy You'll Love This RoleSupportive supervision: Experienced leaders who offer mentorship, guidance, and real-time supportHands-on, impactful work: See the difference you make every day in the fieldCollaborative, mission-driven team that values your voice and expertiseOpportunities for professional growth: Ongoing training, and career advancementCompetitive salary + comprehensive benefits