Case Manager

Job Purpose

The Transition in Place (TIP) Case Manager is responsible for providing comprehensive, client-centered, strengths-based case management services to homeless veterans in our transitional housing programs. This role supports veterans in achieving housing stability, accessing benefits, addressing barriers such as mental health or substance use, and transitioning to permanent housing. The Case Manager works collaboratively with clinical staff, community partners, and VA services to promote self-sufficiency and long-term stability.

Key Responsibilities

Intake & Assessment

• Conduct intake assessments to determine eligibility, strengths, and service needs
• Evaluate psychosocial, emotional, medical, and behavioral needs

Service Planning

• Develop, implement, and update individualized service plans (ISPs) with measurable goals focused on housing, employment, health, and wellness within grant requirements
• Set and report out measurable goals with input from the resident and interdisciplinary team

Coordination of Services

• Link residents with internal and external services such as mental health care, substance use treatment, education, employment assistance, and housing resources
• Schedule and coordinate appointments, transportation, and follow-ups

Monitoring & Evaluation

• Daily contact with residents on case load
• Maintain accurate and timely case notes, records, and reports in compliance with agency and funding requirements (e.g., HMIS)
• Regularly review and update service plans based on resident progress
• Track goals and outcomes and document updates in case files

Crisis Intervention

• Respond to resident crises promptly and appropriately
• Implement de-escalation strategies and connect residents with emergency services if necessary

Advocacy

• Advocate for resident rights and access to appropriate resources
• Help residents navigate healthcare, legal, and social service systems
• Facilitate or coordinate life skills workshops or group sessions on topics such as budgeting, job readiness, or wellness

Documentation & Reporting

• Maintain accurate and timely case notes, progress reports, and other required documentation
• Ensure confidentiality and compliance with privacy regulations

Collaboration

• Participate in staff meetings, case conferences, and interdisciplinary team discussions
• Communicate effectively with clinical staff, family members, probation/parole officers, and community partners

Resident Support

• Provide emotional support, guidance, and mentoring to residents
• Educate residents on life skills, coping mechanisms, and independent living strategies

Policy Compliance

• Ensure all activities comply with organizational policies and procedures, as well as applicable laws and regulations
• Assist with audits, inspections, and licensing reviews as needed
• Other duties as assigned or requested

Key Performance Indicators

• 100% of initial individual service plans (ISP) completed within 14 days of admission into the program
• 100% of ISPs reviewed and updated at 30-, 90-, and 120-days post-admission and then quarterly thereafter
• 100% of case notes entered into Clarity within 24 hours, with a minimum of one case note daily
• 100% of case files, both physical and electronic, are self-audited and corrected monthly
• 100% of eligible clients referred to the Continuum of Care within 14 days of being admitted in the program

Qualifications

• Bachelor's degree in social work, psychology, human services, or related field (master's preferred)
• Minimum of two years of case management experience required 3-5 preferred
• Strong knowledge of veterans' issues, housing systems, mental health, and substance use recovery
• Experience working with homeless populations and/or in supportive housing settings
• Excellent interpersonal, crisis intervention, and documentation skills
• Proficiency with HMIS and electronic case management systems preferred
• Ability to manage priorities in a fast-paced, team-oriented environment
• Valid driver's license in good standing