Case Manager

CARE COORDINATION POSITION

Purpose and Goals:

Care Coordination serves to assist individuals who are not effectively connected with the services and supports they need to transition successfully from higher levels of care to effective community-based care. This includes services and supports that affect a person’s overall well-being, such as primary physical health care, housing, and social connectedness. Care Coordination connects systems including behavioral health, primary care, peer and natural supports, housing, education, vocation, and the justice systems. It is time-limited, with a heavy concentration on educating and empowering the person served, and provides a single point of contact until a person is adequately connected to the care that meets their needs.

Care Coordination is not a service in and of itself, it is a collaborative effort to efficiently target treatment resources to needs, effectively manage and reduce risk, and promote accurate diagnosis and treatment due to consistency of information and shared information.1 It is an approach that includes coordination at the funder level, through data surveillance, information sharing across regional and system partners, partnerships with community stakeholders (i.e., housing providers, judiciary, primary care, etc.), and purchase of needed services and supports.

At the provider level, it includes a thorough assessment of needs, inclusive of a level of care determination, and active linkage and communication with existing and newly identified services and supports. Care Coordination assesses for and addresses behavioral health issues as well as medical, social, housing, interpersonal problems/needs that impact the individual’s status.2 It is a mechanism for linking providers of different services to enable shared information, joint planning efforts, and coordinated/collaborative treatment. Engagement of available social supports to address identified basic needs for resources such as applying for insurance/disability benefits, housing, food, and work programs is essential.

3 Care Coordination also facilitates transitions between providers, episodes of care, across lifespan changes, and across the trajectory of illness.4

At the person level, it incorporates shared decision-making in planning and service determinations and emphasizes self-management. Persons served and family members should be the driver of their goals and recognized as the experts on their needs and what works for them.

Care Coordination is not intended to replace case management. Based on the person’s needs and wishes, case management may be a service identified in the person’s care plan that he or she will be referred to. Case management may be ongoing for those determined eligible for this service based on current standards. Once an individual is successfully linked with a case manager, they would assume the responsibilities of coordinating care.

Requirements:

• Bachelors degrees- preferably in social work, psychology, or community mental health
• Experience in the mental health substance abuse field.
• An ability to assess client needs, identify community resources and develop a treatment plan based on needs and resources.
• An understanding of community resources and how they can be accessed throughout the community
• Good communication and documentation skills
  
  
  

Typical Duties:

• Conducting an assessment to identify the client’s needs and barriers. Create an appropriate care coordination plan of action that addresses identified areas of need based on the outcomes of the assessment.
• Acting as a liaison and advocate for clients regarding available and appropriate program services.
• Identifying and maintaining a working knowledge of available community resources to meet the individual needs of each family and ensuring the connection of families to relevant community resources and support.
• Document all pertinent information and ensure that all appropriate forms, such as, but not limited to, TANF documentation, the intake screening form, monthly reviews, care coordination assessment, and care coordination plan of action are completed and uploaded into the electronic medical record accurately and timely. Preparing correspondence, case notes, narratives, and related documents using computer-based applications.
• Assisting clients with identifying and engaging with community supports, as well as discussing and making referrals for immediate service needs.
• Assisting clients in identifying and applying for appropriate benefits and services, offering referrals to other state agencies and other resources to support individuals and families as necessary. Maintains frequent communication with clients of care coordination, reassesses needs, and completes additional referrals and updates to care coordination plan if needed.
• Collecting data on outcomes
• Participating in treatment team meetings.
• Building and maintaining relationships with respect, trust, sensitivity, and confidentiality to the client, coworkers, and partners agencies.
• Participating in national, state, and local meetings, committees, community activities, outreach events, and other team efforts as required.
  
  
  

Benefits include:

• 26 paid days off (PTO) per year to start! PTO increases over time up to 44 days per year!!
• Sell back PTO at 100% value!
• Health insurance
• Vision
• Dental
• Short-term disability
• Supplemental life insurance
• Life insurance is provided at 3 times your annual salary!
• Long-term disability is provided!
• Company-sponsored 401(a), funded at 8.5% to start!! Increase to 14.5% over time.