Job Title: Registered Nurse (RN) – Enhanced Step-Down Program Critical Time Intervention (CTI) and Transitional Residential Setting (TRS) Program
Department: CTI Team/Clinical Services
Location: Nassau County and Suffolk County, NY; community-based position, travel required
Reports To: CTI Team Leader
Pay Class: Part Time
FLSA Status: Non-exempt
Pay Range: $40.87/hour
Last Revised In: August 2026
ORGANIZATION SUMMARY
Family Residences and Essential Enterprises, Inc. (FREE) benefits and proudly supports more than 5,500 individuals with intellectual / developmental disabilities, mental illness and traumatic brain injury. It is the mission of FREE to support people of all abilities reach their full potential and thrive in their communities. FREE provides a diverse array of supports and services including: housing; recovery services; transition to work; employment; day, community and family services; respite; crisis services; education and after school support; specialty health services; and advocacy.
POSITION SUMMARY
The Registered Nurse (RN) on the Critical Time Intervention (CTI) and Transitional Residential Setting (TRS) Team supports adults with behavioral health needs as they transition from hospitals, emergency departments, crisis settings, or other institutions into the community. The RN provides both CTI care management and health services within the scope of nursing practice, integrating physical and behavioral health care, and addressing medical and wellness needs that impact recovery. The RN collaborates closely with mental health professionals, care managers, peer specialists, hospitals, and community-based providers to ensure continuity of care and promote long-term recovery and independence. This is a split position as half of their responsibilities will be to individuals residing in the community as well as individuals residing in the TRS (residence location to be determined).
DUTIES, RESPONSIBILITIES, AND ESSENTIAL FUNCTIONS
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Provides CTI services across all phases (engagement, linkage, monitoring, and transfer of support) to a caseload of 30 adults; 25 adults in the community CTI program and 5 adults in the TRS setting
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Conducts health assessments, monitors physical health needs, and addresses urgent medical issues within nursing scope of practice in both CTI and TRS
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Accompanies individuals to medical, psychiatric, or specialty appointments when appropriate, ensuring follow-up and adherence to treatment recommendations in both CTI and TRS
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Provides education to the supported individuals on health, wellness, and self-management (medications, chronic disease management, nutrition, hygiene, harm reduction, preventive care) in both CTI and TRS
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Collaborates with the individual and team to develop and update person-centered CTI phase plans in both CTI and TRS
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Serves as a liaison between the CTI/TRS Team and community medical providers (primary care, specialists, hospitals, pharmacies, rehabilitation, etc.)
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Participates in weekly CTI team and TRS meetings to review caseloads, support colleagues, and ensure fidelity to the CTI model
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Supports peers and care managers by addressing the medical needs of individuals on their caseloads as appropriate in both CTI and TRS
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Participates in case conferences, discharge planning, and hospital rounds to ensure smooth transitions of care in both CTI and TRS
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Completes documentation of health assessments, nursing interventions, care coordination, and service delivery in compliance with CTI guidance, OMH, OPWDD, DOH, and agency policies.
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Maintains accurate medication lists, monitors medication side effects, and promotes adherence to medication schedules as prescribed in both CTI and TRS.
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Ensures medical crises are addressed in collaboration with the team’s crisis prevention plan inboth CTI and TRS.
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Contributes to program outcomes by reducing hospitalizations, emergency visits, and medical complications through proactive nursing interventions
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Provides health education and training to CTI and TRS staff and peers on recognizing medical conditions, medication management, and emergency response.
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Follows community safety protocols during outreach, home visits, and crisis interventions.
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Participates in professional development and required OMH CTI training (motivational interviewing, trauma-informed care, integrated care).
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Collaborates with agency’s Nursing Administration to receive any clinical oversight pertaining to essential nursing functions.
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Ensures that all required documentation (paper and electronic) is completed /processed appropriately, in a timely manner, and meets quality and compliance thresholds in both CTI and TRS
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Performs other duties as assigned
Responsibilities of All FREE Employees
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Always communicates in a respectful manner with all people including the people we support,supervisors, other valued team members, and members of the community.
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Complies fully with FREE’s confidentiality policies by holding in strictest confidence all information pertaining to members, residents, the people we support and their families, clients, providers, contractors, and employees.
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Meets all safety training requirements; adheres to all safety policies and reports all unsafe conditions; takes measures to prevent accidents and/or eliminate conditions that pose a safety or health risk.
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Coordinates, supports, attends and participates in all required events/ meetings/ reviews/ committees, including ones outside of standard working hours.
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Meets all job requirements and stays in compliance.
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Adheres to FREE’s standard of ethical behavior as outlined in the Employee Handbook and Code of Conduct as well as applicable laws and regulations.
Please note the above duties, responsibilities, and essential functions are a non-exhaustive list, and may be changed by FREE at any time, with or without notice to the employee.
QUALIFICATIONS
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Education:
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Associate’s degree in nursing required; bachelor’s degree in nursing preferred.
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Experience:
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Minimum of two (2) years of registered nursing experience required; experience in community mental health, integrated care, or working with adults with serious mental illness, co-occurring disorders, or complex health needs preferred.
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Experience with hospital discharge planning, care management, or crisis services preferred.
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Specialized Training, Licenses, Certifications:
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Valid and active NYS RN License required
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Complete the CTI certification process within 12 months of hire
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Complete 9.58 designation certification within 6 months of hire
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Knowledge, Skills, Competencies, and Abilities:
oStrong understanding of behavioral health, physical health, and integrated care approaches.
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Knowledge of NYS OMH/OPWDD regulations, community health resources, and hospital-to-community transitions.
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Excellent verbal and written communication, organizational, interpersonal, and documentation skills.
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Commitment to recovery-oriented, person-centered, and trauma-informed practice.
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Other Requirements:
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Valid driver’s license and satisfy criteria to be an agency driver required
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Some evening, weekend, or on-call responsibilities may be required to meet program needs
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A current PPD (tuberculosis) test or equivalent screening (will be administered upon hire if needed)
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A physical examination completed within the last year by a licensed healthcare provider
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Up-to-date immunization records, which may include (but are not limited to) MMR, Varicella, Tdap, Influenza, and COVID-19, in accordance with hospital system protocols and applicable public health guidelines
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Must sign a COVID-19 vaccine declination form if not vaccinated against COVID-19 and elects not to receive the vaccine.
WORK ENVIRONMENT
This role is performed in-person and is community-based with frequent travel to hospitals, homes, community settings, and FREE locations required.
PHYSICAL REQUIREMENTS
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Employee is required to sit, walk and stand for prolonged period of time (at least 8 hours).
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Employee is required to effectively communicate both verbally and in writing.PHYSICAL REQUIREMENTS
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Employee is required to sit, walk and stand for prolonged period of time (at least 8 hours).
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Employee is required to effectively communicate both verbally and in writing.
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Employee is required to operate standard office equipment such as computers, phones, photocopiers, fax and filing cabinets.
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Employee is required to reach with hands and arms.
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Employee is required to bend, stoop, kneel, crouch or stand on a stool as needed.
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Employee is required to be able to lift 50 pounds at a time.
Notwithstanding the above listed physical requirements of this position, FREE will provide reasonable accommodations to allow employees to perform the essential functions of the position, provided such reasonable accommodations do not cause undue hardship on FREE.

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