Case Manager

POSITION SUMMARY

The Enhanced Step-Down (ESD) Specialty Critical Time Intervention (CTI) Case Manager provides specialized, time-limited case management and transitional support to adults with co-occurring Serious Mental Illness (SMI) and Intellectual and/or Developmental Disabilities (I/DD) who are transitioning from hospitals or emergency departments into the community. Utilizing the Critical Time Intervention (CTI) model, the Case Manager facilitates safe transitions by linking individuals to long-term supports, strengthening natural and professional relationships, and reducing the likelihood of hospital readmission or crisis recurrence. This position is part of the New York State Office of Mental Health's (OMH) Enhanced Step-Down Program, which integrates a Specialty CTI Team and a Transitional Residential Setting (TRS) to provide coordinated, person-centered, and trauma-informed care.

DUTIES, RESPONSIBILITIES, AND ESSENTIAL FUNCTIONS

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Provides specialty CTI services with fidelity to the model, focusing on individuals with co-occurring mental health and developmental disabilities.

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Conducts comprehensive Immediate Needs Assessments and develops individualized support and transition plans addressing behavioral health, physical health, housing, benefits, and community integration.

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Collaborates with hospital discharge planners, OPWDD liaisons, and community providers to ensure seamless transitions.

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Facilitates engagement prior to discharge and provides active follow-up throughout the community transition period.

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Coordinates linkages to housing, behavioral health, medical, and developmental services and assists individuals in navigating eligibility processes for OMH, OPWDD, and related systems.

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Supports individuals in developing independent living and coping skills through direct coaching and modeling.

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Assists in creating and implementing Positive Behavioral Support Plans (PBSPs) in collaboration with the Behavior Intervention Specialist and treatment team.

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Provides crisis intervention and de-escalation support in community settings when needed.

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Maintains accurate and timely documentation in accordance with OMH and agency standards.

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Participates in weekly team meetings, case conferences, and individual supervision to maintain program fidelity and clinical alignment.

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Upholds trauma-informed, recovery-oriented, and person-centered care principles at all times.

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Participates in quality improvement, data collection, and outcome reporting activities.

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Ensures that all required documentation (paper and electronic) is completed /processed appropriately, in a timely manner, and meets quality and compliance thresholds.

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Performs other duties as assigned.

Responsibilities of All FREE Employees

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Always communicates in a respectful manner with all people including the people we support, supervisors, other valued team members, and members of the community.

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Complies fully with FREE's confidentiality policies by holding in strictest confidence all information pertaining to members, residents, the people we support and their families, clients, providers, contractors, and employees.

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Meets all safety training requirements; adheres to all safety policies and reports any and all unsafe conditions; takes measures to prevent accidents and/or eliminate conditions that pose a safety or health risk.

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Coordinates, supports, attends and participates in all required events/ meetings/ reviews/ committees, including ones outside of standard working hours.

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Meets all job requirements and stays in compliance.

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Adheres to FREE's standard of ethical behavior as outlined in the Employee Handbook and Code of Conduct as well as applicable laws and regulations.

Please note the above duties, responsibilities, and essential functions are a non-exhaustive list, and may be changed by FREE at any time, with or without notice to the employee.

QUALIFICATIONS

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Education:
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Bachelor's degree in human services, social work, psychology, rehabilitation, or another related field required; master's degree in a human services discipline preferred.

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Experience:
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Minimum of one (1) year of experience providing direct services to individuals with co-occurring Intellectual/Developmental Disabilities (I/DD) and Serious Mental Illness (SMI).

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Minimum of one (1) year of experience navigating OMH and/or OPWDD service systems, eligibility processes, and community resource coordination.

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Prior experience with evidence-based practices such as CTI, ACT, or care coordination is preferred.

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Specialized Training, Licenses, Certifications:
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Completion of Critical Time Intervention (CTI) model certification within 12 months of hire.

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Completion of OMH 9.58 designation certification within 6 months of hire.

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Knowledge, Skills, Competencies, and Abilities:
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Working knowledge of behavioral health and developmental disability services and systems.

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Excellent communication, interpersonal, and organizational skills.

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Ability to work collaboratively within a multidisciplinary team and across systems.

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Strong crisis management, advocacy, and problem-solving skills.

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Proficiency in Microsoft Office Suite and electronic health record systems.

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Commitment to recovery-oriented, person-centered, and trauma-informed care approaches.

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Other Requirements:
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Valid Driver's License and satisfy criteria to be an agency driver required.

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A current PPD (tuberculosis) test or equivalent screening (administered upon hire if needed).

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A physical examination completed within the past year by a licensed healthcare provider.

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Up-to-date immunization records, which may include (but are not limited to) MMR, Varicella, Tdap, Influenza, and COVID-19, in accordance with hospital system protocols and public health guidelines.

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Ability to work a flexible schedule, including evenings and weekends, based on program needs.

WORK ENVIRONMENT

This role is performed in person in an office setting and in the community. Requires both in-person community engagement and remote coordination/documentation. Travel within Nassau and Suffolk Counties and to partner hospitals, residential facilities, and community settings required.

PHYSICAL REQUIREMENTS

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Employee is required to sit, walk and stand for prolonged period of time (at least 8 hours).

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Employee is required to effectively communicate both verbally and in writing.

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Employee is required to operate standard office equipment such as computers, phones, photocopiers, fax and filing cabinets.

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Employee might be required to lift/move light items.

Notwithstanding the above listed physical requirements of this position, FREE will provide reasonable accommodations to allow employees to perform the essential functions of the position, provided such reasonable accommodations do not cause undue hardship on FREE.