Case Manager

Case Manager – Recovery Centers of America

The Case Manager serves as a member of the treatment team by working closely with clinical, business development, admissions, nursing and other members of the multi‑disciplinary team. The Case Manager is responsible for facilitating recovery by addressing each patient's individual needs and coordinating a thorough aftercare plan that will assist the patient achieve the best possible outcomes through their recovery journey.

This includes collaborating with the patient to schedule a mutually agreed aftercare plan of care inclusive of PCP, SUD, MAT and other appointments as well as providing patients with community and other resources that will help ensure their success. The Case Manager serves as a patient advocate, coordinating care with internal and external providers, resources and supports.

The Case Manager engages each patient in their aftercare plan and using teach back method confirms that the patient and their support system understand the plan and the importance of adhering to the plan. The Case Manager serves as the liaison between the patient and all aftercare providers and resources, ensuring the plan has been established, communicated and confirmed prior to discharge.

The Case Manager will also assist patients with any identified outside issues, barriers to accessing care or external stressors that need to be resolved, enabling the patient to focus on treatment (examples: coordination with family for childcare, employer relations, legal concerns, etc.).

The Case Manager works collaboratively with the clinical team to engage, educate and coordinate patient care with the patient, their supports and all external providers to ensure a thorough aftercare plan.

The Case Manager also works closely with external constituents, providing a high level of customer service and satisfaction amongst everyone with whom they interact. Case Managers are responsible for fostering positive relationships between RCA and all stakeholders.

• Obtains applicable signed Release of Information (ROI) forms for all identified providers and resources in the Continued Care Plan (CCP) and other patient resources/supports (Employer/FMLA, Legal, Payer programs, Referral sources, Peer Support, etc.).
• Completes a new patient admission assessment and documents in Avatar within 72 hrs. of admission and obtains patient history, needs, and individual preferences to inform the patient's treatment and aftercare plans. Reviews the completed Biopsychosocial assessment to help identify all life domain need and incorporates into the Continued Care Plan to ensure all identified patient needs are addressed during the stay and or in the patient's continuing care plan.
• Documents at minimum, a weekly progress note that includes patient progress toward discharge, discussions of discharge planning and recommended aftercare plan, actual or potential barriers to the plan and patient's engagement in their aftercare plan. Discharge planning should be documented in Avatar by the second week of stay.
• Initiates and documents all referrals specified in the CCP including contact information and confirms the aftercare plan addresses follow up for substance use, mental health, MAT, Social Determinants of Health and other identified life domains.
• Participates in Multi Disciplinary Team (MDT) meetings and actively contributes to discussion re: recommendations for each individual's aftercare plan, discharge date, services and resources to be included in the aftercare plan and what is needed from other members of the team to help ensure the patient's success with recovery.
• Schedules SUD/MAT appointments within 7 days of discharge and post discharge PCP follow up appointments when possible. Appointments and referrals must be documented in Avatar prior to the patient's scheduled discharge.
• Ensures effective and timely communication of relevant information to post-discharge providers prior to discharge to facilitate a safe and thorough discharge plan.
• Ensures the continued care/discharge plans is solidified 1 week prior to discharge and that a Transitions of Care meeting has been scheduled at least 7 days prior to discharge with the patient, the patient's support system, and the therapist to review the recommended aftercare plan.
• Confirms patient preferences and barriers to care have been identified and addressed in the plan. Ensures all dates, times, contact information, phone numbers, address, etc.. are included in the CCP to help ensure patient's adherence to the plan.
• Assesses patient's comprehension of the aftercare plan through verbal confirmation and verifies patient's clear understanding of post-discharge care instructions through teach back.
• Follows referent protocols and provides timely clinical updates and other information as requested (with signed ROI).
• Follows Payer protocols and facilitates timely patient-payer phone calls, referrals to Payer Peer Support programs and provides other…