Care Transition Manager Jobs in Rochester, NY (NOW HIRING)

Description

East House is a dedicated non-profit organization committed to supporting individuals on their journey to recovery. We provide comprehensive services, including residential support, counseling, peer support and community outreach to empower individuals to overcome mental health and substance use disorders and lead fulfilling lives. Our mission is to foster a supportive environment that promotes healing and long-term recovery.

Position Overview: The Care Coordinator is an integral member of the Social Care Network's Care Team, dedicated to improving community health outcomes. The Care Team focuses on systematically identifying, assessing, referring, and following up with high-need individuals to ensure they receive essential services. By fostering and maintaining critical service connections, the Care Coordinator helps address the health and social needs of Medicaid recipients. Their role ensures successful linkage to Enhanced Services, which provide vital support in areas such as housing, food and nutrition, transportation, and long-term Health Home Care Management.

Responsibilities

Client Services and Goal Achievement:

Partners with clients found eligible for Enhanced Services to assure they are referred and get linked to needed care and supports.

Short Term involvement with a caseload of 25-30.

Care Coordination and Case Management:

Coordinate services across multiple providers, ensuring seamless care transitions.

Serve as the primary point of contact for clients, families, and service providers.

Facilitate access to mental health and substance use treatment, housing, and social services.

Client Advocacy and Support:

Advocate for clients' needs within the healthcare and social service systems.

Empower clients by educating them about their rights and available resources.

Address barriers to care, such as transportation and financial constraints.

Crisis Intervention and Safety Planning:

Respond to clients in crisis, providing de-escalation and linkage to crisis services.

Develop and implement safety plans in collaboration with clients and support networks.

Monitor clients at risk and coordinate emergency interventions as necessary. 

Monitoring and Evaluation:

Track and document client progress using standardized tools and software

Evaluate the effectiveness of interventions and services, making data-driven recommendations. 

Maintain accurate and timely records in compliance with regulatory and organizational standards. 

Collaboration and Team Participation:

  Participate in multidisciplinary team meetings, contributing insights and updates on client progress. 

• Collaborate with peer support specialists, therapists, and medical professionals to enhance client care. 

• Provide information to community partners on mental health and substance use issues and resources. 

Community Engagement and Outreach: 

Build relationships with community organizations and service providers.

Conduct outreach to identify individuals in need of services.

Represent the organization at community events and stakeholder meetings. 

Documentation and Reporting:

Ensure all client interactions and progress are documented accurately according to East House standards and regulatory requirements.

Provide regular updates and progress reports to supervisors and stakeholders regarding client status and goals. 

Note: This job description may not cover all job duties and is subject to change without notice. Job duties, responsibilities, and/or activities may change at any time with or without notice.

East House is an equal opportunity employer. We value diversity and are committed to creating an inclusive environment for all employees.

East House is a proud RMAPI (Rochester-Monroe Anti-Poverty Initiative) Level Up Champion for our commitment to social justice and promoting economic mobility in our community.

Requirements

Requirements

Minimum Education & Experience

Minimum of High School Diploma or GED.

Associate's degree in Human Services, Social Work or other related degree preferred.

Equivalent experience in lieu of education may be considered.

Minimum of 1-3 years' case management experience.

Other Skills/Abilities 

Possess excellent verbal and written communication skills. 

Exceptional customer service skills with commitment to helping others. 

Ability to quickly adapt and be flexible in approach to job tasks and challenges and maintain emotional control under stress. 

Excellent time management skills with exceptional attention to detail and the ability to multi-task and manage multiple priorities with competing deadlines.

Capability to work cooperatively with culturally diverse clients, staff, and community service providers.

 Basic computer literacy, including the ability to use email, conduct online research, and create basic documents (MS Office Suite including Excel, Outlook and Word). 

Licenses/Certifications 

Narcan training preferred.

NYS motor vehicle license, safe driving record and availability of personal vehicle for work.

Competencies

Alignment with East House Values: Integrity, Progressive, Humanistic, Collaborative, Optimistic. 

Commitment to Diversity, Equity, Inclusion & Belonging: Values and embraces the differences, backgrounds, experiences, and opinions of individuals and groups, and promotes an environment where everyone feels respected and included.

Ensures Accountability: Holds self and others responsible and accountable to meet commitments. 

Working Conditions

Traditional office environment. Occasionally subjected to pressure due to time demands. May have to travel to various program locations which may not be accessible for individuals with reduced mobility.

Physical Demands

The physical demands/work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is frequently required to sit, talk, hear, stand, walk, ability to reach above or below shoulders, use hands to type and/or perform light

lifting (up to 25 lbs.), and occasional stair-climbing