Care Manager


Date Posted:
Job Code:
1255 Rev James Polite Ave BX Health Home
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.


1. Conduct initial assessments and periodic reassessments of clients’ needs, including medical, mental health, substance use, financial, housing, and support needs.

2. Develop patient-focused care plans with documented input and approval from other providers and the client in compliance with Health Home standards.

3. Work with the medical staff to develop, implement, and coordinate the care plan for clients with chronic illnesses, such as diabetes, asthma, congestive heart failure, hypertension, behavioral health conditions, and HIV, among other illnesses, based on the Health Home chronic disease care coordination model standards.

4. Work together with the Community Partnerships Department in the coordination of In-field events to perform intakes of eligible clients.

5.Conduct home/field visits and maintain client engagement in accordance with program standards.

6. Coordinate client services with internal and external service providers through regular case conferencing.

7. Document client outcomes from the care plan in the case record and ensure appropriate record documentation for entire caseload

8. Communicate with the CP team about when assignments have been completed

9. Manage time efficiently at events

10.Must be comfortable doing field work in different settings like, but not limited to, shelters, SRO’s, substance abuse programs, mental health facilities and hospitals.

11. Other tasks as assigned.

Minimum Requirements



  • Bachelor’s Degree plus 2 years related experience required.  Masters Degree in related field may be substituted for 1 year experience preferred. 
  • 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. 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.