Care Manager - Community Support Program

The Bridge offers supportive housing and behavioral health services to vulnerable New Yorkers facing behavioral health and substance use challenges. We provide individuals with the tools they need to pursue their dreams and live meaningful lives. The Bridge envisions a world where adults experiencing serious mental illness can live and thrive within their communities. As a recognized leader in developing and operating supportive housing and community-based programs, The Bridge has 70 years of experience helping New Yorkers with mental illness, including those affected by homelessness, incarceration, and institutionalization.

Scope of Position: The Care Manager on the Critical Time Intervention (CTI) Team provides short-term, intensive, and evidence-based support to individuals experiencing critical life transitions. The Care Manager works collaboratively with hospitals, community providers, and support networks to ensure a smooth transition from inpatient or emergency settings to stable community living. This includes assisting clients with discharge planning and connecting them to essential services such as behavioral health care, housing, benefits, and community resources that promote long-term stability and independence. The position serves individuals with complex needs, including histories of trauma, homelessness, incarceration, and long-term hospitalization. Guided by Harm Reduction and Trauma-Informed principles, the Care Manager acknowledges and actively addresses the impact of systemic racism on the predominantly people-of-color communities served, fostering empowerment, equity, and self-advocacy throughout the recovery process.

Essential Position Functions:

• Conduct persistent, assertive outreach using strength-based approaches, starting during inpatient or emergency department visits; engage in community outreach and assess participants’ health and social needs using CTI’s assessments and risk tools for high-risk individuals.
• Participate in after-hours (24-hour) coverage on a rotating basis; join hospital discharge planning meetings to connect participants with appropriate community resources; collect and report data to inform future care, working with team leaders and data analysts.
• Support participants post-discharge by resolving clinical issues and maintaining access to services; build relationships with community providers to ensure service continuity during transitions; assist with appointment navigation, travel training, and overcoming care barriers.
• Conduct psychosocial assessments to evaluate medical, psychiatric, housing, and social needs; gather collateral information to support participants' behavioral and health needs; monitor and document participants’ progress toward care plan goals.
• Attend team meetings and supervisory sessions; perform other related duties as assigned.