Family Recovery & Environmental Case Manager

Valcore Health Growing Rural Opportunities for Well-being (GROW)

Region/Program:
Region7/ Mobile Integrated Health (MIH), Mobile Healthcare & Screening Services, Improve Infant & Maternal Health, and Navigating Distance-Based Health Disparities

Approved

E.1 Position:
Family Recovery & Environmental Case Manager (Social Worker)

Initiative Allocation:
Mobile Integrated Health

Grant Cost Class:
Programmatic/ non-administrative

Staffing Basis 1.0 FTE; one funded position per current

E.1

Reports To:

GROW Program Director or designee

Clinical Accountability:
Indiana LCSW supervisor when social-work practice or LSW/LBSW supervision is required; designated clinical lead for safety escalation.

Position Status:
Year One funded position, subject to final award, approved

E.1, and hiring plan.

Coordinate whole-family recovery, environmental and social-needs response, and closed-loop connections so high-risk families can engage with clinical care and remain connected through pregnancy, postpartum, recovery, and other vulnerable transitions.

Region 7, with primary field deployment in Washington, Harrison, and Crawford counties and expansion within the approved regional service area; home-, community-, partner-site-, mobile-, and telehealth-enabled care for high-risk pregnant and postpartum people and their families.

• Work as part of Region 7's single in-place model joining prenatal, postpartum, reproductive, behavioral-health, psychiatric, addiction, and family-support services.
• Use coordinated referral, documentation, escalation, and partner workflows with BLOOM, Well Care FFM, Life Choices, hospitals, OB/GYN, local health departments/WIC, DCS, and other approved coalition partners.
• Lead whole-family social/environmental stabilization and closed-loop resource work so clinical access gains are sustainable outside the encounter.
• Support MIH re-engagement, partner case conferences, and quarterly maternal-child-health workshops with de-identified/system-level learning where appropriate.

earlier prenatal connection, full-term and healthy-birth-weight outcomes, new access points, closed-loop referrals, and durable clinical/community integration. The role is accountable for its documented work and care-process contribution, not for claiming sole causation of population outcomes.

• Complete role-appropriate social, environmental, family-safety, recovery, access, and resource assessments using approved tools; identify urgent needs and escalat[e] clinical or safety concerns immediately.
• Develop and update person- and family-centered service plans with clear goals, responsible parties, due dates, consent, and follow-up steps.
• Connect participants to housing, food, transportation, benefits, legal, domestic-violence, child/family, recovery, treatment, and other community resources; verify whether connections were completed and barriers resolved.
• Provide intensive outreach and re-engagement for missed visits, transitions, hospital/ED discharge, treatment interruption, or changing family risk.
• Coordinate with clinical staff, DCS and other public agencies when legally and operationally appropriate, hospitals, local health departments/WIC, recovery organizations, and community partners using valid consent and minimum-necessary information.
• Support recovery-oriented planning, relapse-risk response, practical family stabilization, and environmental risk reduction without providing psychotherapy or independent clinical treatment unless separately licensed, privileged, and assigned.
• Maintain a current resource inventory, surface service gaps to the coalition, and help test referral and escalation workflows.

VALCORE HEALTH GROW REGION 7 | JOB DESCRIPTION

• Follow the approved GROW grant agreement, current
  
  E.1 budget justification, regional work plan, logic model, outcome-measure appendix, Valcore policies, and written grant-change controls. Do not materially alter the funded purpose, FTE allocation, initiative assignment, or deliverable without authorized approval.
• Create timely, accurate, auditable source documentation for services, outreach, referrals, training, partner activity, time and effort, travel, deliverables, and role-relevant outcomes. Support CMS/State monitoring, quarterly and annual reporting, audits, corrective actions, and record-retention requirements.
• Protect information under HIPAA, 42 CFR Part 2 when substance-use-disorder records are involved,…