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

Health Home Plus (HH+) Care Manager
Be 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 Transitions
As 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 Do
• Coordinate safe, smooth transitions from hospitals, detox/rehab centers, and psychiatric inpatient facilities
• Conduct frequent field visits to client homes, shelters, hospitals, and community agencies
• Develop and manage comprehensive, individualized care plans addressing medical, behavioral, and social needs
• Collaborate closely with providers, discharge planners , and community partners to ensure continuity of care
• Connect clients with housing, benefits, outpatient treatment, peer supports , and other vital services
• Monitor risk factors, ensure follow-ups, and advocate fiercely for each client's stability and wellness
• Support clients in navigating complex healthcare and social systems with compassion and clarity

What You'll Bring
• Bachelor'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 conditions
• Strong background in care transitions, discharge planning, community outreach , or case management
• A self-starter who is comfortable with extensive fieldwork and building community relationships
• Excellent communication, organization, and problem-solving skills
• Commitment to trauma-informed, person-centered care

Why You'll Love This Role

Supportive supervision : Experienced leaders who offer mentorship, guidance, and real-time support

Hands-on, impactful work : See the difference you make every day in the field

Collaborative, mission-driven team that values your voice and expertise

Opportunities for professional growth : Ongoing training, and career advancement

Competitive salary + comprehensive benefits