RN Case Manager

Registered Nurse (RN) Targeted Case Manager

Great outcomes start with great people and Armor has an exciting opportunity for a Registered Nurse (RN) Targeted Case Manager to join our team at Erie County Prison in Erie, PA.

Responsibilities

Eligibility Identification & Tracking

• Screen incarcerated individuals for eligibility under Waiver 5121 (behavioral health / targeted populations) and the CMS 1115 Reentry Waiver.

• Maintain a real-time tracking log and dashboard of all eligible individuals.

• Prioritize individuals within 30–90 days of anticipated release.

Care Coordination

• Coordinate services across medical, behavioral health, and substance use disorder (SUD) treatment.

• Serve as primary liaison between the facility clinical team, County Behavioral Health, Medicaid Managed Care Organizations (MCOs), and community treatment providers.

Pre-Release Planning

• Develop individualized Reentry Care Plans for each eligible individual, including diagnoses and treatment plans, medication continuity (including MAT), and follow-up appointments scheduled prior to release.

• Assist with discharge planning and ensure discharge packets are complete, accurate, and transmitted to receiving providers in collaboration with the clinical team.

Medicaid Activation & Authorization

• Facilitate Medicaid enrollment or reactivation for eligible individuals prior to release.

• Coordinate prior authorizations for services to ensure coverage is active at time of release.

Continuity of Care (Warm Handoff)

• Link patients to community-based treatment providers and coordinate direct warm hand-offs to MAT programs, mental health providers, and primary care upon release.

• Confirm follow-up appointment attendance when possible and track high-risk individuals post-release as permitted by applicable regulations.

Documentation & Compliance

• Maintain accurate and timely documentation of all case management activities in the EMR and/or tracking system in compliance with HIPAA and organizational standards.

• Maintain accurate documentation in facility and/or behavioral health record systems in accordance with HIPAA, CMS 1115 / 5121 Program requirements, PA DHS guidelines, NCCHC discharge planning standards, and criminal justice policies.

Quality & Reporting

• Track outcomes and report key performance indicators including percentage of eligible individuals identified, care plans completed, Medicaid activated pre-release, follow-up appointments scheduled, and reductions in 30-day ER utilization and 30/60/90-day recidivism.

• Participate in case reviews, staff meetings, quality assurance reviews, audits, and ongoing professional development.

• Participate in multidisciplinary conferences, facility reentry planning meetings, and specialized court dockets.

• Provide education to patients, court officials, clinic staff, and community members about behavioral health, substance use disorder, recovery, and available services.

• Advocate for patients' needs and help overcome barriers to care such as transportation, insurance, or housing while balancing safety, clinical standards, and correctional protocols.

• Will adhere to Armor's core values: embrace change, take ownership, attention to detail, sense of urgency, results oriented and collaborative environment.

• Respond to requests from Security Staff as well as Armor Staff in accordance with Armor and Facility Guidelines. This includes always following the rules and regulations for employee conduct/behavior and chain of command set forth by the command staff while working within the detention/correctional facility.

• Performs other duties as assigned.

Community Involvement

SAMHSA guidelines emphasize that community MAT providers should offer a recovery-oriented system of care. The TCM serves as Armor's and the Sheriff's Office liaison to community treatment providers and in-reach staff who visit the correctional facility to see medical and behavioral health patients, including community-based substance abuse programs, public health and mental health agency staff, Medicaid MCOs, and others.

• Manages relationships with key community providers to foster patient compliance, satisfaction, and positive reentry outcomes.

• Attends select community meetings on a limited basis when coordination is required between community-based organizations and the facility medical and behavioral health program.

Qualifications

• Licensure required: Registered Nurse
• Minimum of 2–3 years of experience in case management, behavioral health, substance use disorder treatment, or correctional healthcare (preferred).
• Knowledge of Medicaid, waiver programs (including Waiver 5121 and CMS 1115), and MCO processes strongly preferred.
• Familiarity with MAT programs (e.g., methadone, buprenorphine, naltrexone), trauma-informed care, and motivational interviewing.
• Strong care coordination, systems navigation, communication, organizational, and interpersonal skills.
• Ability to work collaboratively in a multidisciplinary team environment.
• Experience working with justice-involved individuals or in correctional settings preferred.
• Must pass a background check and obtain facility clearance.

Other relevant professional experiences or educational backgrounds will be considered as deemed appropriate. However, when licensure is required by local, state, federal, or contractual guidelines, Armor will not alter its position on those requirements.

If you want to join an exciting, dynamic and growing organization that is making a positive impact on the lives we serve, we look forward to speaking with you!

At Armor Health we are raising the standard of care to impact the lives of those we serve by partnering with exceptional correctional organizations to improve health care outcomes. We provide support for patients and foster the holistic wellness and well-being of the lives entrusted in our care. Armor is laser-focused on providing the best-in-class interventions to ensure optimal outcomes. Through our core values of embracing change, taking ownership, attention to detail, a sense of urgency, and a results oriented collaborative environment, we are a dynamic team that is transforming and revolutionizing correctional healthcare.

Armor Health is committed to providing equal employment opportunity for all qualified employees and applicants. We comply with all applicable federal and state laws prohibiting discrimination in employment, including but not limited to those that prohibit discrimination based on color, religion, sex, pregnancy, sexual orientation, genetic information, national origin, immigration status, age, physical or mental disability, military or veteran's status, and citizenship.

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