Central Health’s Medical Bridge is an innovative program that fills gaps in care for vulnerable individuals, especially those experiencing homelessness. We see patients at our Capital Plaza location as well as various mobile sites. The Case Manager acts is a critical member of the team who would provide intensive case management for patients that we see through the Bridge Program.

The Medical Respite Case Manager is a critical member of the multidisciplinary respite team providing intensive case management for patients who are seen in the program, supporting patients until we are able to connect them successfully to a medical home. This support includes welcoming new patients, screening for non medical drivers of health needs, engaging with them as needed, and coordinating their social needs as well as linkages to medical and behavioral services. The case manager is skilled in crisis management, and provides timely referrals to appropriate substance abuse, physical health and mental health treatment, support in accessing benefits and entitlements, and support in identifying appropriate and affordable housing as part of a comprehensive approach to ending
homelessness and achieving self-sufficiency.

Essential Functions:

• Develops individualized treatment plans and psychosocial goals for short- and long-term care plans by assessing individual needs, strengths, barriers and readiness to change
• Provides crisis intervention services (assessment, evaluation of risk, referral and follow up)
• Effectively de-escalate heightened situations with patients experiencing trauma, exacerbated mental health symptoms, and behavioral complexity
• Provides goal oriented and short oriented services (engagement, case management, counseling linkage) with complex psychosocial needs
• Educates patients on available community resources
• Teaches patients through structure and modeling appropriate expectations and guide them on following through with their tasks
• Helps patients identify and manage challenges or barriers in navigating health and government benefits
• Accompany patients to appointments as needed
• Assists patients directly or indirectly with housing survey (Coordinated Assessment)
• Works with patients on discharge planning by reviewing potential transitional housing programs, assisting with room rental search and applications for housing units
• Collaborate with housing specialists and/or other resources to identify and address psychological, social and medical needs, and coordinates referrals for housing programs
• Works collaboratively with treatment team, community resources and partner agencies involved in patient’s care and participates in weekly case conference with multidisciplinary respite team to discuss patient’s care plan
• Assists respite team as needed in patients in coordinating transportation for appointment, picking up medications and other support services
• Other duties as assigned

Knowledge, Skills and Abilities:

• High level of skill at building relationships and providing excellent customer service 
• High level of problem-solving skills to better serve patients and staff 
• Strong attention to detail and accuracy 
• Excellent verbal and written communication skills 
• Demonstrated knowledge of community resources available and how to access resources for the benefit of clients 
• Demonstrated success in collaborating with multidisciplinary team members 
• Bilingual (Spanish/English) preferred 

Required Education:

• Bachelor's degree in Social Work or related field (higher degree accepted)

Required Experience (Less than 1 year):

• Internship or work in field related to social work, case management, or counseling individuals in crisis/trauma situations.
• Demonstate knowledge of community resources available and how to access resources for the benefit of clients