Description

Compensation Range: $46,000 - $50,000 commensurate with experience.

Position Overview

The Care Manager will implement effective prevention strategies to serve New York City’s most at-risk queer communities, with a focus on transgender, gender non-conforming (TGNC) individuals, and men who have sex with men (MSM) of color. In this dynamic role, the Care Manager will provide comprehensive care coordination for SAMHSA program participants, from enrollment to discharge. This includes conducting GRPA assessments, developing individualized care plans, and coordinating access to essential services such as primary care, mental health counseling, substance use treatment, housing, and vocational/educational resources. The Care Manager will also participate in fieldwork, outreach, and evidence-based program interventions to support clients effectively.

Responsibilities

• Provide supportive case management to Transgender, Gender Non-conforming, and Gender Non-binary (TGNC) individuals and Men who have Sex with Men (MSM) of color who are at high risk for substance abuse and/or co-occurring mental health conditions.
• Conduct GRPA intake, follow-up, and discharge assessments for all program participants.
• Offer ongoing care coordination and participate in integrated case conferences to support treatment adherence and improved health outcomes.
• Follow up with clients and providers to ensure appointment adherence, engagement in care, and access to necessary treatment.
• Engage clients via social media for outreach, re-engagement, and case management follow-up activities in compliance with HIPAA protocols.
• Maintain essential data for reporting and program evaluation in eICare, including program enrollments, progress notes, care plans, and referral activity.
• Build and maintain comprehensive resource lists for external services and emergency resources (e.g., housing, domestic violence support, food pantries).
• Coordinate with outreach staff to identify and address the needs of new enrollees in the program.
• Facilitate presentations for internal and external programs to promote program services and attract new enrollees.
• Participate in weekly supervisory sessions with the Program Coordinator.
• Contribute to monthly chart reviews and participate in Continuous Quality Improvement (CQI) site meetings and programmatic projects.
• Ensure successful referrals and linkages to psychosocial services, including warm hand-offs.
• Participate in daily huddles with clinic staff to discuss client needs and coordinate care as needed.
• Collaborate with multidisciplinary team members and external partners to address clinical barriers to care.
• Perform various administrative duties, including updating client trackers, outreach logs, assisting with outreach calls, and scheduling intakes and follow-ups.
• Attend interdisciplinary team meetings as a program representative and provide updated information in preparation for meetings.
• Perform other duties as assigned by the supervisor to support program goals.