Services for the Underserved

  • Team Leader, Pathway Home

    Job Location US-NY-New York
    Treatment Services
    Regular Full-Time
  • Position Overview

    The Team Leader will be a Licensed Mental Health Professional and will work on a new NYS Office of Alcoholism and Substance Abuse Services (OASAS) funded innovative care transition team that exclusively serves individuals transitioning to the community from an Inpatient Detox and/or Rehabilitation stay. The role will involve facilitating transition from Inpatient Detox and/or rehabilitation to the community by addressing the preparatory needs of participants in the early stages of recovery, discharge planning, development of daily living skills, and coping mechanisms through group and individual work in the community. The team will follow individuals into the community using the Pathway Home model of care to ensure that they become both linked and engaged with identified community providers and that their support network is enough to meet their needs. The role will require some on call coverage.



    Job Responsibilities:


    • Engagement beginning during inpatient detox or rehab stay, involvement in transition planning, and a needs assessment of community transition supports essential to stabilizing the individual;
    • Monitors appropriate discharge and ongoing care planning at pre- and post-transition for individuals being discharged from an inpatient stay.
    • Acts as a liaison and collaborates with community providers, Managed Care Plans, and Housing Contractors.
    • Short term counseling (substance use, coping skills, trauma informed, decision making) and Risk Assessment/Safety Planning;
    • Provide supervision to team members and orient new team members to policy and procedures as well as ongoing training and mentorship;
    • Collects, analyzes, and reports data, as required while managing and adhering to productivity standards,
    • Facilitate and lead staff meetings. Participate in all meetings, as assigned. Facilitate and monitor the organizing of team member’s schedule, assisting with time management as needed.
    • Participate in both the development and implementation of a community care plan that includes formal and informal supports that increase opportunities for improved quality of life. Focus is on creating meaningful and productive daily activities in the community;
    • Assessing Housing Supports and Housing Assistance and Placement for those who are homeless. Services may include completing HRA 2010e, applying for housing, prepping for interviews, follow up with housing providers, and assistance with moving in (day of move) with obtaining housing supplies and learning the neighborhood;
    • Work with recipients and their housing providers to resolve clinical issues that are impacting on the recipient’s ability to obtain, manage, and retain supportive housing;
    • Foster relationship with community provides to ensure that recipients are connected with appropriate services as they transition back into the community and to share or collect collateral information;
    • Patient navigation by accompanying to first behavioral health and medical appointment, travel training, reengagement in community care, referral to services with ability to identify and address potential services and barriers to obtain and maintain such services
    • Review documentation and conduct comprehensive psychosocial assessments to determine the medical, psychiatric, housing and other social needs in the community. Obtain historical and collateral information from multiple sources as it relates to mental and physical health, substance use, and criminal history;
    • Develop a short-term person centered treatment plan to assist the recipients’ towards achieving their goals, related and unrelated to their recovery, and modify treatment plans according to changes in recipients’ status.
    • Monitor, evaluate and record recipient progress with respect to treatment goals;
    • Establish collaborative working relationships with inpatient treatment teams, community providers, and other partners and plan with them for appropriate discharges for recipients;
    • Counsel recipients in individual and group sessions to assist them in dealing with substance abuse, mental and physical illness, family issues, housing problems and unemployment;
    • Provide ongoing family conferences and psychoeducation to families and others within the support network;
    • Provide out of hours crisis intervention services to recipients and their support network, including respite referrals and other diversion and stabilization services;
    • Attend and participate in team meetings and supervisory sessions;
    • Perform other related duties as assigned;


    Essential Knowledge, Skills and Abilities:


    • Knowledge of mental illness and serious emotional disturbances and substance abuse disorders.
    • Knowledge of treatment, rehabilitation, and community support programs as they relate to consumers/residents, families, and staff.
    • Knowledge of techniques for identifying and preventing potentially violent behavior, including crisis management techniques.
    • Experience with group work.
    • Ability to develop, evaluate, implement and modify a clinical treatment intervention to meet the needs of individual recipients.
    • Ability to prepare accurate and timely reports


    • Master’s degree or higher in social work, mental health counseling, nursing or psychology.
    • A minimum of 3 years post-masters work experience in the mental health and criminal justice field, preferably with the target population.



    Company Overview

    Services for the UnderServed (S:US) believes every New Yorker has the right to lead a life of purpose. Since 1978, S:US has been turning this belief into reality by advocating for people with life circumstances marked by homelessness, intellectual/developmental disability, behavioral health and addiction challenges, poverty, criminal justice involvement, and trauma. Our dedicated workforce of 2,400 provides services and supports to transform the lives of 35,000 individuals and families in New York City and Long Island. Learn more about S:US, our mission, and values by visiting


    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


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