Outreach Care Manager

Responsibilities of the Outreach Case Manager:

• Engage individuals identified by the Schenectady County Outreach HUB and assessing for eligibility and needs based on the individual’s identified goals.  Complete referrals to community resources and ongoing assessment process.  Work towards resolution of long-standing issues that affect smooth delivery of care, individuals' stability in the community, and health promotion.
• Attend Schenectady County Outreach HUB Boots on the Ground Meetings as scheduled and communicate with other HUB members on an ongoing and as needed basis.
• Provide weekly intensive case management services to individuals until they have been connected to permanent Health Home Care Management agencies.
• Provide comprehensive transitional care from inpatient to other settings to ensure individuals are linked with necessary services upon discharge from an inpatient setting or a transition to another service provider.
• Regularly communicate with other care providers to coordinate the exchange of information and identify other care requirements and needs.  Monitor service delivery and ongoing engagement.  Advocate for additional services as needed.
• Provide transportation to clients using the agency’s vehicles
• Promote a culture of inclusion and belonging.