Case Manager

Description

DESCRIPTION:

Under the direct supervision of the Director of Behavioral Health and Case Management or designee, the Case Manager I provides comprehensive case management services for patients eligible for Enhanced Care Management (ECM) or Complex Care Management (CCM). This role supports patients with complex medical, behavioral, and social needs, serving as a key member of the interdisciplinary care team. This position upholds the organization’s mission, vision, and values through excellence, collaboration, innovation, respect, commitment to the community, accountability, and ownership.

The Case Manager I develops and implements individualized care management plans, supporting patients across physical health, mental health, substance use disorders (SUD), community-based long-term services, oral health, palliative care, social supports, and social determinants of health. Essential ECM and CCM activities include patient outreach, screenings, comprehensive assessments, preventative care, care coordination, advocacy, health promotion, crisis navigation, transitional care, and referral to community and social services.

General Case Management Duties:

• Conduct outreach and engagement efforts to connect patients with ECM/CCM services. This includes and is not limited to in-person community based field visits
• Perform screenings and comprehensive intake assessments to determine patient needs and eligibility.
• Independently manage a caseload of patients within productivity standards.
• Develop, implement, and monitor patient goals and progress within individualized Care Management Plans (CMPs) in collaboration with patients, providers, social support networks, and the interdisciplinary care team.
• Maintain up-to-date, accurate documentation within the electronic health record (EHR), ensuring timely data collection and compliance with reporting and documentation requirements.
• Facilitate warm hand-offs and ensure closed-loop referrals to appropriate healthcare and social service providers.
• As a care team leader, support patients in accessing and utilizing healthcare services, including medical, behavioral, dental, and substance use treatment, preventive care, and chronic disease management.
• Provide education and training on self-management skills to improve patient health outcomes.
• Assist patients in accessing public benefits (e.g., SSI, Cal Fresh, cash aid) and gathering necessary documentation. Facilitate referrals to Community Health Services when appropriate.
• Advocate for patient needs and assist in overcoming barriers to care, including transportation and appointment scheduling.

Mental Health Crisis Navigation:

• Utilize de-escalation and Motivational Interviewing techniques to manage crisis situations effectively.
• Conduct risk assessments for patients experiencing acute mental health distress and coordinate with crisis response teams as needed.
• Provide supportive interventions to stabilize patients and facilitate engagement with appropriate mental health services.
• Maintain communication with emergency responders, hospitals, internal staff, and behavioral health teams to ensure continuity of care.
• Offer psychoeducation to patients and their families on coping strategies and crisis prevention.
• Follow up with patients and their families to ensure they are receiving the appropriate level of care in a timely manner.

Group Facilitation and Support Services:

• Work collaboratively with behavioral health providers and/or medical providers to facilitate psycho educational and support groups addressing topics such as chronic disease management, mental health, substance use recovery, and social skills development.
• Provide patient-centered coaching and peer support in group settings to promote shared learning and self-efficacy.

Comprehensive Transitional Care:

• Coordinate hospital and institutional discharge planning as well as internal case management services, ensuring seamless transitions between level of care needs.
• Develop and implement transition care plans, including follow-up appointments, medication reconciliation, and adherence support.
• Work with community-based organizations to secure necessary post-discharge services and supports.
• Monitor patients post-discharge to prevent readmissions and improve long-term health outcomes.

Community Collaboration and Advocacy:

• Develop and maintain professional relationships with internal and external stakeholders to enhance care coordination efforts.
• Serve as a liaison between patients, providers, and community resources, advocating for patient needs.
• Participate in interdisciplinary team meetings, case reviews, and collaborative problem-solving discussions.
• Stay informed of local and statewide policies affecting patient access to services and advocate for improvements in care delivery.

Compliance and Professional Development:

• Adhere to organizational privacy, security, and compliance policies, including HIPAA and OSHA regulations.
• Engage in ongoing professional development through…