Care Manager; Hybrid-Remote

Care Manager (Hybrid-Remote)

Join to apply for the Care Manager (Hybrid-Remote) role at AltaPointe Health Systems.

• Chart Review and Documentation
  • Conduct structured reviews of clinical records to assess service utilization, client engagement, and treatment plan compliance.
  • Document all findings and coordination efforts in the electronic health record using the Care Manager System.
  • Identify gaps in care, missed services, or follow‑up needs and take appropriate action.
• Care Coordination
  • Coordinate physical, behavioral, and social health services across internal programs and external providers.
  • Facilitate client access to community‑based services such as housing, benefits, employment supports, and substance use care.
  • Ensure referrals are generated, tracked, and closed with appropriate documentation.
• Hospital Discharge and Transition Support
  • Conduct follow‑up calls within 24 hours of psychiatric or medical hospital discharges.
  • Confirm follow‑up appointments are scheduled, and discharge instructions are supported and understood.
  • Notify care team members of transitions and facilitate continuity of care.
• Service Monitoring and Engagement
  • Monitor client attendance at therapy, psychiatry, and medical appointments.
  • Address patterns of disengagement, such as missed appointments, and initiate outreach or peer support referrals.
  • Review PHQ-9 and other screening tools to track clinical progress and inform care needs.
• Referral and Linkage Management
  • Create, follow up, and close referrals in the Care Manager System.
  • Communicate with service providers to confirm that referrals were completed and appointments attended.
  • Resolve barriers such as transportation, insurance, or documentation needs.
• Risk Identification and Response
  • Monitor client risk levels and report any significant changes to the treatment team.
  • Support crisis response planning by facilitating communication across care team members and community resources.
• Treatment Plan Support
  • Assist with treatment plan implementation by ensuring services align with identified goals and timelines.
  • Coordinate updates to the treatment plan as client needs or engagement levels change.
• Ongoing Caseload Management
  • Manage assigned client caseloads, respond to alerts, and complete scheduled reviews as outlined in care protocols.
  • Participate in team huddles and interdisciplinary case discussions.
• Compliance and Reporting
  • Ensure documentation meets agency, Medicaid, and CCBHC standards.
  • Maintain timely and accurate entries in line with quality assurance requirements.
• Productivity Standard
  • Care Managers are expected to dedicate the majority of their workday to direct patient care coordination activities.
  • 80–90% of time is spent on chart reviews, outreach attempts, care coordination tasks, referral management, documentation, and follow‑up.
  • During initial training, focus is on building proficiency; chart review volume may vary by case complexity.
  • Once fully trained, maintain a consistent workflow aligned with the 80–90% target.
  • Daily responsibilities include fully working all hospital/ED/BHCC follow‑ups, completing missed appointment follow‑ups, prioritizing referrals by patient risk, and completing daily documentation.

• Education
  • Bachelor’s degree in behavioral health, human services, nursing, public health, or related field preferred.
  • Alternatively, high school diploma or equivalent with 4 years of experience in behavioral health, care coordination, case management, or related healthcare service delivery.
• Experience
  • Minimum of 2 years in behavioral health, care coordination, case management, or related healthcare service delivery.
  • Experience with high‑need populations (SMI, SED, SUD) strongly preferred.
• Skills and Competencies
  • Strong knowledge of behavioral health systems, including mental health, substance use, and social determinants of health.
  • Proficiency in navigating and documenting within electronic health records (EHR), including coordination systems like Avatar or equivalent.
  • Experience with treatment planning, interagency coordination, and client engagement.
  • Strong organizational and communication skills, with ability to document accurately and follow up on tasks.
  • Ability to work independently and as part of an interdisciplinary team.
• Other Requirements
  • Valid driver’s license and reliable transportation may be required based on program location.
  • Ability to pass background checks and credentialing per agency standards.

Entry level

Full‑time

Health Care Provider – Hospitals and Health Care

AltaPointe Health Systems is an Equal Opportunity Employer. All qualified applicants will receive consideration without regard to race, color, religion, sex, gender identity, sexual orientation, national origin, disability, or veteran status.