Professional I, Behavioral Health Specialist;Permanent Supportive Housing;368

Job Summary:
Permanent Supportive Housing (PSH) is a model that combines low-barrier, affordable housing, health care, and supportive services to help individuals and families achieve and maintain housing stability. PSH typically serves individuals who are experiencing homelessness or housing instability, face multiple barriers to housing, and require supportive services to maintain long-term stability.
Under the direction of the Manager, Permanent Supportive Housing, the Case Manager contributes to the PSH Care Team by providing strength-based case management services to individuals with a history of chronic homelessness, behavioral health conditions, and other psychosocial needs. This role promotes wellness, housing stability, and housing retention through integrated care coordination, service planning, supportive interventions, and linkage to internal and external resources that address whole-person health needs, including medical care, behavioral health care, substance use services, and social determinants of health.
Essential Duties and Responsibilities:
• Engagement, Assessment, and Client Support
◦ Explain the purpose, expectations, and process of case management services to clients and support informed participation in services.
◦ Obtain relevant information from clients and collateral sources to assess strengths, needs, preferences, safety, well-being, activities of daily living, instrumental activities of daily living, and immediate service needs.
◦ Administer appropriate screening and assessment tools to support shared decision-making, goal setting, and individualized service planning.
◦ Establish and maintain positive, therapeutic relationships with clients through face-to-face, telephonic, office-based, property-based, and community-based engagement.
◦ Engage clients through assertive outreach to identify wellness needs, service preferences, barriers, and opportunities for support.
◦ Support clients in developing independent living skills, including budgeting, paying bills, understanding leases, and maintaining housing stability.
• Service Planning, Case Management, and Housing Stability
◦ Review assessment and screening outcomes with clients to prioritize needs and develop immediate, short-term, and long-term service goals.
◦ Develop and maintain individualized service plans and housing success plans that reflect client strengths, needs, measurable goals, timeframes, and case management strategies.
◦ Provide individualized case management, care coordination, and Therapeutic Behavioral Services in settings that meet the needs of the client.
◦ Provide behavioral health interventions based on client presentation, assessed needs, preferences, medical necessity, and applicable evidence-based practices.
◦ Apply Housing First, Harm Reduction, Motivational Interviewing, Stages of Change, Stage-Wise Interventions, and other evidence-based approaches to support wellness and housing stability.
◦ Provide ongoing pro-social support and life skills training on an individual and group basis to promote independence, wellness, and housing retention.
◦ Conduct ongoing monitoring to assess progress, evaluate the effectiveness of service plan strategies, and adjust interventions as needed.
◦ Appropriately transition or terminate case management services, including providing reasonable notice and supporting continuity of care when applicable.
• Coordination, Linkage, and Monitoring
◦ Work collaboratively with the multidisciplinary service team, including counselors, nurses, physicians, pharmacists, social service staff, Property Management, and the PSH Care Team to support positive client outcomes.
◦ Identify, maintain, and use knowledge of community resources to connect clients with supports related to housing, neighborhood and environmental needs, social supports, peer and community needs, economic needs, education, vocational goals, and other social determinants of health.
◦ Make formal and informal referrals to service providers identified in the case management plan and follow up to address barriers to care, resources, and services.
◦ Support clients following hospitalization or other transitions in care to promote community functioning and reduce avoidable emergency room or hospital utilization when possible.
◦ Assist clients with linkage to primary care, behavioral health, substance use, and other needed services, including attending appointments, transporting or accompanying clients, and addressing transportation barriers as needed.
◦ Identify and address barriers to medication adherence, medical appointments, behavioral health appointments, benefit access, and service engagement.
◦ Assist clients with ben