Case Manager

Overview

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Job Description - Case Manager (260000LL)

The Human Service Coordinator I (Case Manager) provides assessment, outreach, support, service coordination and person-centered advocacy to DMH authorized adults by promoting DMH’s philosophy of recovery, trauma informed care, person-centered choices, and cultural humility by utilizing strength-based goal setting and through independent decision-making. Responsible for development, implementation and monitoring of individual service plans; assists individuals in securing services and performs all duties to reflect the highest level of dignity for persons served.

Duties and Responsibilities

Provides creative engagement strategies including regularly scheduled face-to-face contact in accordance with the needs of the person served, family and other community providers to engage and sustain involvement in attaining the individual’s goals and maintaining community tenure.

Directly provides assistance and support with, but not limited to, housing search, employment search, skill development, symptom management, wellness management, and encourages active participation in treatment by developing positive therapeutic relationships.

Regularly schedules visits to occur in the client’s home or usual place of residence, as appropriate, and monitors safety of the environment.

Prepares and maintains documentation according to DMH regulations and Electronic Health Record (EHR) business rules including progress notes and other required documentation.

Develops a comprehensive assessment of individual needs in accordance with DMH regulations and timelines by interviewing the individual, family &/or LAR, significant others; obtaining records; gathering relevant written and verbal information from past & current service providers in order to determine the service needs.

Develops, implements, and monitors the individual service plan (ISP) per DMH regulations and timelines with the individual and service providers; convenes and facilitates meetings to review and modify the ISP, when indicated.

Develops a critical needs assessment of individual needs and a critical needs plan in accordance with DMH regulations and timelines for designated individuals receiving Critical Needs Case Management. Interviews the individual, family &/or LAR and significant others, obtains records, gathers relevant written and verbal information from past and current service providers to determine the critical service needs.

Conducts in person screenings and needs & means assessments to identify need for services, respond to requests for interim services and recommend &/or refer to services as appropriate.

Refers individuals for specialized assessments and to programs and services, including entitlements, that are indicated by the Comprehensive Assessment and ISP.

Monitor and ensure that services and entitlements are in place and meeting the individual’s identified needs.

Coordinates transitions by facilitating communication with providers and families to ensure individuals are receiving needed services in a timely manner.

Directly engages with individuals throughout all housing and care settings (inpatient jail, shelters, SNF, etc.) to ensure access to needed services, coordination and communication among service providers and to facilitate efficient transitions and/or diversions.

Leads discharge planning & service coordination activities to support community transitions or diversion of individuals to ensure a smooth transition to the community.

Links individuals to appropriate agencies & organizations to meet individual needs identified through the ISP process and ensure that necessary services are provided in the least restrictive environment. Participate in utilization management reviews to monitor efficient use of resources.

Identifies historic & current risk factors of assigned individuals and collaborates with the individual, Supervisor, crisis intervention services, & service providers to facilitate and participate in appropriate assessment and planning.

Facilitates and participates in the development of plans to address risk & safety for…