Care Manager

Overview

Care Managers perform clinical record reviews, care coordination, and ongoing caseload management to ensure service utilization, client engagement, treatment plan compliance, and continuity of care across internal programs and external providers. They document in the Care Manager System and collaborate with the care team to remove barriers and facilitate access to community-based services.

• 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: 80-90% of time on patient care coordination, including chart reviews, outreach attempts, care coordination tasks, referral management, documentation, and follow-up. During initial training, chart reviews per day may vary based on learning needs and case complexity.
  
  Once fully trained, maintain a consistent workflow aligned with 80-90% of time on patient care coordination tasks. Daily responsibilities include completing all assigned follow-ups and prioritizing referrals by patient risk.
• Daily Responsibilities – Fully work all Hospital/ED/BHCC follow-ups, complete all missed appointment follow ups, and work referrals in order of patient risk.

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.