Location: New York, New York 10004

SCOPE OF ROLE:

Licensed Mental Health Professional to work on a new funded innovative care

transition team that serves participants transitioning to the community from a higher level of

care. The role will involve facilitating transition from one level of care to the community by

addressing the preparatory needs of participants in the early stages of recovery, discharge

planning, development of daily living skills, and coping mechanisms through team and

individual work in the community. The team will follow participants into the community using

the Pathway Home model of care to ensure that they become both linked and engaged with

identified community providers and that their support network is enough to meet their needs.

The role will require some on call coverage. 

ESSENTIAL DUTIES & RESPONSIBILITIES:

• Engagement beginning from referring location with involvement in transition planning, including a needs assessment of community transition supports essential to stabilizing the individual
• Monitor appropriate discharge and ongoing care planning at pre- and post-transition for individuals transitioning to community.
• Establish collaborative working relationships and act as a liaison with community providers, Managed Care Plans, and Housing Contractors.
• Short term counseling (coping skills, trauma informed, decision making) and Risk Assessment/Safety Planning.
• Provide supervision to team members and orient new team members to policy and procedures as well as ongoing training and mentorship.
• Collects and reports data, as required while adhering to productivity standards
• Participate in both the development and implementation of a community care plan that includes formal and informal support that increase opportunities for improved quality of life. Focus is on creating meaningful and productive daily activities in the community.
• Assessing Housing Supports and Housing Assistance and Placement for those who are homeless. Services may include completing HRA 2010e, applying for housing, prepping for interviews, follow up with housing providers, and assistance with moving in (day of move) with obtaining housing supplies and learning the neighborhood.
• Work with participants and their housing providers to resolve clinical issues that are impacting on the participant’s ability to obtain, manage, and retain supportive housing.

• Foster relationship with community provides to ensure that recipients are connected with appropriate services as they transition back into the community and to share or collect collateral information.
• Appointment navigation by accompanying to first behavioral health and medical appointment-including but not limited to travel training, reengagement in community care, and ability to identify needs and barriers to services as well as making appropriate referrals.
• Review documentation and conduct comprehensive psychosocial assessments to determine the medical, psychiatric, housing and other social needs in the community.
• Obtain historical and collateral information from multiple sources as it relates to behavioral and physical health, substance use, and criminal history.
• Monitor, evaluate and record participant progress with respect to care plan goals.
• Counsel participants in individual and group sessions to assist them in dealing with substance abuse, mental and physical illness, family issues, housing problems and unemployment and other social determinants of health.
• Provide ongoing family conferences and psychoeducation to families and others within the support network.
• Provide on-call after hour crisis intervention services when needed to participants and their support network, including respite referrals and other diversion and stabilization services.
• Attend and participate in team meetings and supervisory sessions.
• Perform other related duties as assigned.

REQUIRED EDUCATION AND EXPERIENCE:

REQUIRED EDUCATION AND EXPERIENCE

·       Master’s degree or higher in social work, Mental health counseling, nursing or psychology.

·       A minimum of 3 years post-masters’ work.

·       Experience in the behavioral health and/or criminal justice field, preferably with the target population.

·       Effective written and oral communication skills.

PREFERRED QUALIFICATIONS & SKILLS

·       Knowledge of mental illness and serious emotional disturbances and substance use

disorders.

·       Knowledge of treatment, rehabilitation, and community support programs as they relate to

recipient/residents, families, and staff.

·       Knowledge of techniques for identifying and preventing potentially violent behavior,

including crisis management techniques. 

·       Experience with group work.

S:US IS AN EQUAL OPPORTUNITY EMPLOYER 

Join a team of employees who cares about the wellbeing of others. We’re proud to offer a comprehensive benefits package designed to support your wellbeing and development. From health and wellness resources to generous PTO, professional development, and more, explore all that we offer on our Benefits Page and see how S:US invests in you. 

We believe in fostering a culture built on our core values:  respect, integrity, support, maximizing individual potential and continuous quality improvement.  

S:US is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, or genetic information. S:US is committed to providing access, equal opportunity and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities, including allowance of the use of services animals. To request reasonable accommodation or if you believe such a request was improperly handled or denied, contact the Leave Team at MyMedicalLeave@sus.org.