Program Population
The NENB Housing program is an interim housing program that supports individuals experiencing homelessness as they work toward greater stability, independence, and improved quality of life. Participants may have a variety of individual needs and circumstances, which may include mental health or substance-use concerns. Individuals served by the program may occasionally experience periods of emotional distress or heightened frustration that can result in verbal disagreements, raised voices, or other challenging interactions.
Position Purpose
The Case Manager provides comprehensive case management services to participants of the Pathway Home program, including individuals and families experiencing homelessness and individuals who may have complex behavioral health or substance-use needs. Reporting to the Program Manager, the Case Manager assesses participant needs, develops individualized service plans, and coordinates appropriate resources and supportive services to promote stability, well-being, and progress toward identified goals.
The Case Manager works closely with participants and a multidisciplinary team to facilitate communication, coordinate services, monitor progress, address barriers, and advocate for appropriate resources and support. The position requires a professional, respectful, and person-centered approach when working with participants with diverse needs and experiences.
Principal Responsibilities
- 1. Collaborate with healthcare providers, managed care plans, the Housing Navigation Team, and community-based homeless service providers to facilitate coordinated care and supportive services for eligible Pathway Home participants. 2. Provide comprehensive case management services, including intake, assessment, individualized service planning, implementation, referrals, monitoring, and follow-up. 3. Assess participants' needs and connect them with appropriate health, behavioral health, housing, transportation, benefits, and community-based resources and services. 4. Accompany or assist participants with accessing appointments and community services when appropriate and consistent with program guidelines. 5. Advocate for participants when communicating with healthcare providers, social service agencies, and other community partners to help ensure their needs, preferences, and goals are appropriately addressed. 6. Utilize motivational interviewing, trauma-informed approaches, harm-reduction strategies, and other evidence-informed practices to build rapport, support participant engagement, and promote positive outcomes. 7. Collaborate with clinical and supportive service staff to develop appropriate transition and discharge plans and facilitate continuity of care and services. 8. Support participants in following recommended treatment and care plans, including medication management, when applicable and within the scope of the position. 9. Provide health promotion, wellness education, and self-management support to help participants develop skills and strategies that promote greater independence and well-being. 10. Conduct and document comprehensive initial and ongoing assessments of participant needs, including housing status, functional needs, behavioral health, substance use, education, benefits, and other factors affecting stability. 11. Develop, maintain, and regularly update Individual Service Plans (ISPs) in collaboration with participants, documenting progress toward identified goals and addressing barriers as needed. 12. Provide appropriate referrals and linkages to services, including healthcare, behavioral health, housing, food assistance, transportation, benefits assistance, employment or educational resources, and other community supports. 13. Assist participants in understanding and accessing eligible public assistance and benefits programs, including Medi-Cal, SSI, General Relief (GR), housing programs, and other applicable resources. 14. Maintain accurate and timely documentation of case management activities, participant progress, referrals, outcomes, and other required program data. Complete monthly reports and other reporting requirements in accordance with program and funding requirements. 15. Participate in weekly case conferences with clinical staff, supervisors, and other members of the multidisciplinary team to discuss participant needs, coordinate services, address barriers, and support effective case management. 16. Participate in agency, program, and community meetings, quality improvement activities, case conferences, and required in-service trainings. 17. Maintain confidentiality and protect the privacy of participant, employee, and organizational information in accordance with applicable laws, regulations, and organizational policies. 18. Adhere to all organizational safety policies, procedures, and regulatory requirements to ensure a safe environment for patients, staff, and visitors. 19. Participate in required safety and compliance trainings and apply learned practices in daily work activities. 20. Identify, report, and help mitigate unsafe conditions, incidents, or hazards in the workplace. 21. Use equipment, tools, and supplies safely and responsibly in accordance with organizational and regulatory standards. 22. Maintain awareness of infection control, occupational health, and emergency preparedness procedures appropriate to the role. 23. Participate in JWCH’s customer service training called AIDET on an annual basis.
