Responsibilities
Primary Job Functions:
Clinical:
- 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. Productivity expectations are as follows:
- Care Managers will spend 80-90% of their time on patient care coordination, which includes chart reviews, outreach attempts, care coordination tasks, referral management, documentation, and follow-up.
- During the initial training period, Care Managers will focus on building proficiency with workflows, documentation standards, and chart review processes. During this time, the number of charts reviewed per day may vary based on learning needs and case complexity.
- Once fully trained and able to conduct efficient and thorough chart reviews, Care Managers will be expected to maintain a consistent workflow that aligns with spending 80-90% of time on patient care coordination tasks.
- Daily Responsibilities: Each day, Care Managers are expected to:
- Fully work all Hospital/ED/BHCC follow-ups assigned to them.
- Complete all missed appointment follow ups.
- Work referrals in order of patient risk, ensuring high risk patients are prioritized, followed by moderate-high risk, and then moderate- and low-risk referrals.
- Documentation must be completed daily to support timely follow-up, continuity, and closed-loop care coordination.
Supervision and Consultation:
- Seeks supervision and consultation as needed.
- Accepts and employs suggestions for improvement.
- Actively works to enhance care management skills
Clinical Record Keeping:
- Documents interactions with patients and chart reviews.
- Documents within Care Manager appropriate follow up and provision of linkage to services.
Courteous and respectful attitudes towards patients, visitors, and co-workers:
- Treats patients with care, dignity, and compassion.
- Respects patient's privacy and confidentiality.
- Is pleasant and cooperative with others.
- Personal values don't inhibit ability to relate and care for others.
- Is sensitive to the patient's needs, expectations, and individual differences.
Caseload Management:
- Effectively manages caseload based on patient needs and staffs with supervisor regularly.
Administrative and Other Related Duties as Assigned:
- Actively participates in Performance Improvement activities.
- Actively participates in AltaPointe committees as required.
- Follows AltaPointe policies and procedures
- Attends required in-service training and other workshops, trainings.
Qualifications
Minimum Qualifications:
Education:
Bachelor's degree in a behavioral health, human services, nursing, public health, or related field is preferred -or- High School diploma or equivalent and 4 years of experience in behavioral health, care coordination, case management, or related healthcare service delivery.
Experience:
Minimum of 2 years of experience 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, including 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.
