Intensive Care Manager


Date Posted:
1255 Rev James Polite Ave BX Health Home
New York
United States of America



The Care Manager works with clients and the client’s network of providers to help minimize barriers to care and help clients achieve improved health outcomes. Using interventions such as care coordination, motivational interviewing and health promotion, care managers help clients, over the course of time, develop the skills needed to manage their health and psychosocial needs with greater independence. Care Managers will have the opportunity to work as part of outcome driven integrated teams and participate in agency wide quality improvement activities aimed at improving the delivery of care to individuals living with chronic illness, behavioral health issues, and homelessness.


· Maintain a caseload of 15-20 High Need Clients who are diagnosed with (Human Immunodeficiency Virus/Sever mental illness) HIV/SMI or both

· Assess clients’ needs for services and cooperatively develop an intergraded care plan and goals with the client/family and other providers. Maintain documentation and update care plans at specific time intervals or as needed in Housing Works and Health Home electronic medical records system

· Work and communicate effectively with interdisciplinary team of providers, including Primary Care Provider, psychiatrist, therapist, substance abuse treatment programs and other providers. Attend Integrated Case Conferences as scheduled.

· Work with the client to identify barriers to goal attainment and help resolve those barriers, i.e., keeping scheduled appointments with appropriate service providers, medication regimen for adherence while promoting good health

· Must conduct 2 face to face visits monthly

· Maintain weekly engagement with clients

· Conduct field work, to client’s home and other provider settings, as needed to fulfill plan of care

· Coordinate transitional care from an inpatient service to other settings as per care plan

· Closely monitor ER visits for frequency and work with clients to prevent frequent ER visits

· Obtain hospital and incarceration discharge summaries

· Maintain documentation of diagnosis and ongoing lab reports for clients

· Work collaboratively with team members to provide outreach and engagement to hard to reach clients

· Provide assistance through advocacy and psycho-education to client and family for entitlements and other community services

· Performs other duties as requested


Minimum Requirements



· Masters Degree in related field  required working directly with clients who are diagnosed with (Human Immunodeficiency Virus/Sever mental illness) HIV/SMI or both

· Computer literate and working knowledge of Microsoft Office (Word, Excel)

· Good interpersonal skills and ability/interest in working as part of a team.

· Knowledge of HIV, substance use, homelessness, mental illness, and other chronic medical conditions

· Knowledge of City, State, and Federal entitlement systems is helpful.

Housing Works provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements. Housing Works complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. Housing Works also does not request prior salary information during the hiring process. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.This position is included in a bargaining unit of Housing Works’ New York City employees represented by a labor union known as the Retail Wholesale and Department Store Union (“RWDSU”). Accordingly, the RWDSU has the exclusive right to bargain over the terms and conditions of employment related to this position and this position may become covered by the terms of a collective bargaining agreement (a “CBA”) between Housing Works and the RWDSU