Responsibilities:
Primary Job Functions:
Clinical:
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Chart Review and Documentation
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Conduct structured reviews of clinical records to assess service utilization, client engagement, and treatment plan compliance.
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Document all findings and coordination efforts in the electronic health record using the Care Manager System.
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Identify gaps in care, missed services, or follow-up needs and take appropriate action.
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Care Coordination
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Coordinate physical, behavioral, and social health services across internal programs and external providers.
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Facilitate client access to community-based services such as housing, benefits, employment supports, and substance use care.
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Ensure referrals are generated, tracked, and closed with appropriate documentation.
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Hospital Discharge and Transition Support
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Conduct follow-up calls within 24 hours of psychiatric or medical hospital discharges.
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Confirm follow-up appointments are scheduled, and discharge instructions are supported and understood.
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Notify care team members of transitions and facilitate continuity of care.
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Service Monitoring and Engagement
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Monitor client attendance at therapy, psychiatry, and medical appointments.
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Address patterns of disengagement, such as missed appointments, and initiate outreach or peer support referrals.
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Review PHQ-9 and other screening tools to track clinical progress and inform care needs.
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Referral and Linkage Management
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Create, follow up, and close referrals in the Care Manager System.
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Communicate with service providers to confirm that referrals were completed and appointments attended.
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Resolve barriers such as transportation, insurance, or documentation needs.
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Risk Identification and Response
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Monitor client risk levels and report any significant changes to the treatment team.
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Support crisis response planning by facilitating communication across care team members and community resources.
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Treatment Plan Support
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Assist with treatment plan implementation by ensuring services align with identified goals and timelines.
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Coordinate updates to the treatment plan as client needs or engagement levels change.
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Ongoing Caseload Management
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Manage assigned client caseloads, respond to alerts, and complete scheduled reviews as outlined in care protocols.
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Participate in team huddles and interdisciplinary case discussions.
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Compliance and Reporting
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Ensure documentation meets agency, Medicaid, and CCBHC standards.
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Maintain timely and accurate entries in line with quality assurance requirements.
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Productivity Standard
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Care Managers are expected to review an average of 8-10 charts per day as they build familiarity with the process and complete full chart reviews.
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Once training is completed and review skills are developed, productivity will increase to 15-20 chart reviews per day, depending on chart complexity, and new patient chart reviews.
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Documentation of reviews must be completed daily to ensure timely follow-up and coordination of care.
Supervision and Consultation:
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Seeks supervision and consultation as needed.
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Accepts and employs suggestions for improvement.
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Actively works to enhance care management skills
Clinical Record Keeping:
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Documents interactions with patients and chart reviews.
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Documents within Care Manager appropriate follow up and provision of linkage to services.
Courteous and respectful attitudes towards patients, visitors, and co-workers:
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Treats patients with care, dignity, and compassion.
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Respects patient’s privacy and confidentiality.
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Is pleasant and cooperative with others.
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Personal values don’t inhibit ability to relate and care for others.
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Is sensitive to the patient’s needs, expectations, and individual differences.
Caseload Management:
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Effectively manages caseload based on patient needs and staffs with supervisor regularly.
Administrative and Other Related Duties as Assigned:
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Actively participates in Performance Improvement activities.
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Actively participates in AltaPointe committees as required.
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Follows AltaPointe policies and procedures
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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:
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Strong knowledge of behavioral health systems, including mental health, substance use, and social determinants of health.
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Proficiency in navigating and documenting within electronic health records (EHR), including coordination systems like Avatar or equivalent.
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Experience with treatment planning, interagency coordination, and client engagement.
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Strong organizational and communication skills, including ability to document accurately and follow up on tasks.
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Ability to work independently and as part of an interdisciplinary team.
Other Requirements:
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Valid driver’s license and reliable transportation may be required based on program location.
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Ability to pass background checks and credentialing per agency standards.
