Complex Needs Case Manager

Position Summary

The Complex Needs Case Manager provides intensive, person-centered case management to neighbors experiencing homelessness who have high and complex service needs, including serious mental health needs, chronic health conditions, housing instability, and other barriers to achieving and maintaining housing stability.

Working as a member of The Stewpot team and under the program direction and coordinated care framework of Housing Forward, the Complex Needs Case Manager works closely with partner agencies including DDI, Metrocare Services, Parkland Health, Housing Forward, housing providers, behavioral health providers, and other community partners.

This position serves neighbors who may require a higher level of coordination and engagement than traditional case management. The Complex Needs Case Manager is responsible for building trusting relationships, developing individualized service plans, coordinating care across multiple systems, reducing barriers to housing and services, and supporting neighbors as they move toward housing stability, improved wellness, and greater independence.

The position requires strong relationship-building skills, sound judgment, persistence, flexibility, and the ability to effectively work with individuals experiencing significant behavioral health and other complex challenges.

Essential Duties & Responsibilities

Identification Case Management & Neighbor Engagement

• Maintain an assigned caseload of neighbors identified as having high or complex service needs.
• Build trusting, consistent relationships with neighbors who may have historically experienced difficulty engaging with traditional service systems.
• Provide individualized case management focused on helping neighbors obtain, replace, or update essential identification documents.
• Assess identification-related needs, barriers, and eligibility requirements and develop individualized action plans.
• Assist with applications for birth certificates, state-issued identification cards, Social Security cards, and other essential documents.
• Help neighbors gather required documentation, complete forms, schedule appointments, and navigate government and community service systems.
• Follow up consistently with neighbors and service providers to monitor progress and resolve barriers.
• Develop individualized service plans with neighbors based on their priorities, strengths, barriers, and housing goals.
• Provide services using a person-centered, trauma-informed, strengths-based, and housing-focused approach.
• Help neighbors navigate barriers that may interfere with housing placement or housing stability.

Behavioral Health & Complex Needs Coordination

• Work closely with neighbors experiencing significant mental health needs, behavioral health challenges, substance-use concerns, chronic medical conditions, or multiple co occurring needs.
• Recognize changes in behavior or circumstances that may indicate the need for additional clinical, medical, or crisis intervention.
• Coordinate with qualified behavioral health and healthcare professionals rather than attempting to provide clinical services outside the scope of the position.
• Facilitate connections to mental health treatment, primary care, medication management, substance-use services, benefits, and other appropriate resources.
• Participate in multidisciplinary discussions regarding neighbors with particularly complex needs.
• Collaborate with community partners to coordinate and support neighbors’ attendance at appointments, including transportation arrangements, appointment reminders, and follow up to address barriers to successful participation.

Housing Stability

• Support neighbors in maintaining housing stability by identifying immediate needs, barriers, and available community resources.
• Assist neighbors experiencing housing instability by connecting them with emergency and ongoing supportive services.
• Connect neighbors with local food pantries, meal programs, food assistance benefits, and other community food resources.
• Coordinate the distribution or provision of clothing, personal hygiene products, household essentials, and other basic-needs supplies.
• Coordinate with Housing Forward, housing providers, landlords, and other partners involved in the neighbor's housing plan. Support newly housed neighbors during the transition from homelessness into housing.
• Identify risks that could lead to housing loss and coordinate interventions as early as possible.
• Help neighbors develop skills and connections that support long-term housing stability.

Crisis Response & Safety

• Recognize and appropriately respond to behavioral health crises and other situations requiring immediate intervention.
• Follow established Stewpot and partner protocols for crisis response and escalation.
• Coordinate with behavioral health professionals, healthcare providers, emergency services, security, or other appropriate resources when necessary.
• Maintain professional boundaries while providing compassionate and persistent engagement.
• Complete incident reports and required follow-up documentation. Immediately communicate significant safety concerns according to established procedures.

Documentation & Data Management

• Maintain timely, accurate, and professional case notes.
• Document assessments, contacts, referrals, services, progress, barriers, and outcomes.
• Enter required information into HMIS and/or other designated systems in accordance with program requirements.
• Maintain documentation necessary for grants, contracts, audits, and program compliance.
• Protect confidential neighbor information and follow applicable privacy requirements.
• Track neighbor progress from engagement through housing placement and housing stabilization.
• Participate in case reviews and quality-assurance activities.