Services for the Underserved

  • Outreach Specialist

    Job Location US-NY-Bronx
    Homeless Services
    Regular Full-Time
  • Position Overview

    Company Overview: As a leading provider of residential and support services to individuals with special needs, Services for the UnderServed provides the resources you need to build on your experience amidst our culture of team support. Ongoing training and attention to your development help to ensure your success. Your achievements and leadership are rewarded by advancement opportunities. Our commitment to continuous quality improvement impacts the lives of our clients and communities while contributing to the development of our employees.


    Position Summary:

    The SRO Outreach Project works with homeless and formerly homeless people with HIV/ AIDS and seeks to connect them to medical services and stabilized housing; The Transitional Care Coordination Program (TCC) employs the Critical Time Intervention model to assist individuals to access the supports they need and develop those long term helping relationships. The Care Coordination Program (MCM) employs a navigation model and a chronic care model to advocate for, communicate with, and identify resources for the client as well as encourage and support clients to gain and maintain independence in their healthcare to ensure improved client health outcomes and improved quality of life.


    The Outreach Specialist will be trained in both models and service protocols and  may be assigned to work with clients of either program as needed. 



    • Responsible for direct, field based services to enrolled consumers.
    • Responsible for conducting Case Finding with the TCC team at SRO field sites.  Recruit and screen SRO Residents who may be eligible for services of either program.
    • Responsible for supporting the implementation of a comprehensive Service Plan for each enrolled consumer.
    • Assists consumers with securing services for housing, medical care, nutrition and transportation. Assists consumers with relevant applications and other paperwork for benefits and support services. Conduct regular social services and benefits re-assessments and follow ups.
    • Visit enrolled consumers at their homes, including at SRO Hotels, between regular clinic visits to reinforce treatment plans, provide appointment reminders, provide individual health education curriculum, coordinate transportation and health care needs and other follow up activities as warranted.
    • Accompany consumers to all primary care, specialty care and other health care appointments. Accompany consumer to other social service appointments as warranted.
    • Provide field-based Directly Observed Therapy Services to consumers assessed to require this service. DOT includes observing and recording patient medication intake, compliance levels and assessing and reporting any side effects.
    • Provide critical feedback to the other members of the health care team based on observations in the field.
    • Record all service provision on Field Logs (or “mappings”) for submission to the Data Entry Specialist on a Daily basis.
    • Document all services in AWARDS Case Management Software.
    • Collect and record Primary Care Status Measures data as assigned.  
    • Participate in daily planning meetings with SRO Intervention Project Team. Periodic participation in team meetings, case conferences, division meetings and trainings as required
    • Participate in Services for the Underserved Quality Assurance/ Quality Improvement activities
    • Evening and weekend hours may be required.


    Benefits Overview: We offer attractive compensation with comprehensive benefits including: Medical/Dental/Prescription/Vision/Life Insurance;403(b); Credit Union; FSAs; Short-and-Long-Term Disability; Transportation Plan; Generous Paid Vacations and Holidays



    • High School Diploma or GED required; some college or degree preferred.
    • Experience working with people living with AIDS, homeless people and substance users required.
    • Bi-lingual preferred.
    • Experience working within an outreach model preferred.
    • NYS Driver’s License preferred





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