Conduct home visits, community outreach, and engagement using a culturally sensitive, trauma-informed approach to build trust with adults living with chronic medical, mental health, and/or substance use conditions.
Complete comprehensive, consumer-driven assessments to identify strengths, challenges, and service needs; develop and regularly update individualized care plans reflecting client goals, preferences, and wellness objectives.
Coordinate and monitor behavioral health, physical health, and social service supports in alignment with each client’s needs and service plan.
Build and maintain linkages with both natural supports (family, friends, community) and formal resources, including hospitals, outpatient clinics, rehabilitation programs, self-help groups, housing agencies, and social service providers.
Manage a caseload of approximately 40–50 clients, providing consistent contact through home visits, phone calls, and field-based engagement in accordance with client acuity and program standards.
Advocate for and coordinate care across multiple systems: medical, behavioral health, and social service, to ensure access to comprehensive, continuous, and integrated care.
Monitor client progress toward goals, supporting self-management and helping to reduce preventable hospitalizations and emergency room utilization.
Collaborate closely with multidisciplinary providers and participate in joint case reviews, ensuring coordinated, goal-directed care.
Maintain detailed, accurate, and timely documentation in the electronic health record (EHR), ensuring all required clinical and eligibility documents meet standards set by the Department of Health, Office of Mental Health, Health Home program, Suffolk County Division of Mental Hygiene, and Family Service League.
Participate actively in supervision, team meetings, and case conferences, including ACM staff meetings and agency-wide meetings, to share resources, address client needs, and contribute to program improvement.
Maintain a positive, professional rapport with the Suffolk County Adult SPOA and other referral sources to facilitate client enrollment and smooth transitions of care.
Respond promptly to crises or urgent client needs, implementing safety plans and coordinating follow-up support.
Serve as a role model of professionalism and FSL’s mission, promoting empathy, empowerment, and recovery-focused practice.
Complete all required reports and documentation accurately and within established timelines to support billing, compliance, and program outcomes.
Follow all agency and program policies and mandates, including confidentiality, safety, and quality assurance standards.
Perform other related duties as assigned to support program operations and the overall mission of Family Service League.
Requirements
Bachelor’s Degree in a health-related field is required.
Minimum of 2 years of experience providing direct services to people with serious mental illness, medical conditions, developmental disabilities, and/or substance abuse preferred.
Proficiency in Microsoft Office required; experience with an EHR is preferred.
Strong assessment, engagement, organizational and time management skills.
Excellent verbal and written communication skills are required.
Valid and clean New York State Driver’s License required.
Benefits
Health and Dental Insurance
Vision Insurance
Flexible Spending Account (FSA)
Retirement Savings Plan with a 5% employer contribution
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