Case Manager (SOS) - Community Support Program

The Bridge offers supportive housing and behavioral health services to vulnerable New Yorkers facing behavioral health and substance use challenges. We provide individuals with the tools they need to pursue their dreams and live meaningful lives. The Bridge envisions a world where adults experiencing serious mental illness can live and thrive within their communities. As a recognized leader in developing and operating supportive housing and community-based programs, The Bridge has 70 years of experience helping New Yorkers with mental illness, including those affected by homelessness, incarceration, and institutionalization.

Scope of Position: The SOS team, consisting of a Director, Assistant Director, Clinicians, Care Managers, a Nurse, and a Peer Specialist, will apply the evidence-based Critical Time Intervention (CTI) model to support participants transitioning from the street to stable housing. The Case Manager will engage in community outreach, assist with daily living skills, accompany participants to appointments, and advocate for them against discrimination or healthcare inequities. The role emphasizes member choice, harm reduction, and person-centered care. SOS teams will continue supporting participants post-housing placement for several months to ensure stability and well-being. The position requires fieldwork, on-call coverage, flexible hours, and offers training in CTI and professional development opportunities.

Essential Position Functions:

• Persistent and assertive outreach and engagement using strength-based approaches beginning either at known “hang-outs” or “Hot spots” within the transit system or during an inpatient hospital admission or emergency department visit.

• Continuously assess the health and social needs of participants through SOS’s conversational and observational assessments and formalized risk assessment tools for those identified as being at high risk.

• Work in collaboration with the centralized SOR Hub to identify available housing and to support participants through the process. Tasks may include completing HRA 2010e, applying for housing, prepping for interviews, following up with housing providers, and assistance with moving in (day of move) obtaining housing supplies, and learning the neighborhood.

• Participate in hospital discharge planning meetings to identify the best community resources for returning patients.

• Collects and reports data, as required, and works closely with team leaders, data analysts, and other SOS teams to use data to inform future care delivery.

• Once housed work with participants and their housing providers to resolve clinical issues that are impacting on the participant’s ability to manage and retain supportive housing.

• Foster relationships with the community to ensure that recipients are connected with appropriate services as they transition back into the community.

• Appointment navigation, including accompaniment to appointments, travel training, reengagement in community care, and addressing barriers to care.

• Review documentation and conduct comprehensive psychosocial assessments to determine the medical, psychiatric, housing, and other social needs in the community.

• Obtain historical and collateral information from multiple sources to support the behavioral and physical health needs of participants.

• Monitor, evaluate, and record the progress of participants with respect to care plan goals.

• Attend and participate in team meetings and supervisory sessions.

• Perform other related duties as assigned.