C2C LMSW​/LPC Case Manager

Licensed Master Social Worker (LMSW) or Licensed Professional Counselor (LPC) license is required.

GENERAL DESCRIPTION

The C2C LMSW Case Manager is a split position with .5 FTE dedicated to providing comprehensive case management and care coordination services to individuals with chronic or complex physical and/or behavioral health needs, with a focus on those recently released from incarceration. The TCM works as part of a multi-disciplinary care team to ensure patients gain access to appropriate medical, behavioral health, substance use disorder (SUD), educational, and social services.

Services include assessments, planning, linkage, advocacy, monitoring, education, and follow-up support. The remaining .5 FTE for this position will be focused on providing therapeutic services to adult patients diagnosed with Behavioral Health Disorders and Substance Use Disorders (as well as other co-occurring disorders). Responsibilities include, but are not exclusive to: psychosocial assessments, diagnoses, individual therapy, group therapy, treatment planning, psychoeducation, referrals and consultations.

• Conduct comprehensive assessments of medical, behavioral, and social needs, particularly for individuals transitioning from incarceration.
• Develop, implement, and monitor individualized care plans in collaboration with the patient, care team, and other providers.
• Facilitate linkage to primary care, behavioral health, SUD services, and community resources.
• Provide education, counseling, and ongoing support to patients and their families regarding health conditions, treatment plans, and recovery goals.
• Coordinate care transitions and advocate on behalf of patients to reduce barriers to accessing care.
• Participate in an integrated team approach to patient care/treatment. Treatment team will include physicians, RNs, peer recovery coaches, clinicians, etc.
• Monitor patient outcomes, reassess needs, and adjust care plans as appropriate.
• Maintain timely and accurate documentation in accordance with Medicaid, state, and federal requirements.
• Collaborate with Medicaid health plans, corrections systems, and community partners to ensure continuity of care for justice-involved individuals.
• Respond to crises and provide appropriate interventions within scope of practice.
• Provide individualized behavioral health treatment to consumers: including initial psychosocial assessment, diagnoses, individualized treatment plans and on-going therapy sessions
• Maintain a therapy caseload that appropriately meets the needs of patients, utilizing evidence-based practices, best care practices, industry standards, organizational guidelines, appropriate accreditation standards, and applicable federal laws, including HIPAA
• Refer patients for more specialized or inpatient interventions as clinically appropriate.
• Maintain quality care through participation in peer review, weekly case review meetings, policy development and quality improvement programs as requested
• Complete all documentation in an appropriate, timely manner and in accordance with third party compliance standards
• Maintain and update professional knowledge and proficiency through continuing education, staff meetings and other resources specific to providing integrated behavioral and mental services in a federally qualified health center
• Schedule flexibility (e.g. one evening shift per week, ability to work from different sites as needed)

• Strong clinical assessment and case management skills.
• Knowledge of behavioral health and substance use disorder treatment models, evidence-based practices, and recovery-oriented approaches.
• Provide effective individual therapy services to patients receiving treatment for substance use disorders
• Initiate and maintain an individualized treatment plan, document progress in treatment, and ability to secure re-authorizations for services
• Ability to assist and support patients in developing/implementing a recovery plan
• Comfortable conducting Tele-health and in-person comprehensive assessments, evaluations and developing treatment plans
• Demonstrated knowledge of HIPAA and ability to handle confidential information appropriately.
• Participation in ongoing professional development, training, and team meetings, commitment to integrated, patient-centered care and support of organizational quality improvement initiatives.
• Ability to build rapport and maintain effective working relationships with culturally diverse populations, providers, and community partners.
• Excellent organizational, time management, and problem-solving skills.
• Proficiency with electronic medical records (EMR), Microsoft Office, and telehealth platforms.
• Strong written and verbal communication skills.
• Ability to work both independently and collaboratively in a multidisciplinary team.
• Schedule flexibility, including occasional evening shifts and willingness to travel between MyCare sites and community locations as needed.

• Must maintain strict…