Case Manager - Pathways to Recovery

POSITION TYPE: Hybrid

PAY RANGE: $48,000 - $59,000 depending on years of experience

POSITION SUMMARY

The Case Manager is part of Pathways to Recovery (PTR): A Reentry Diversion Initiative, an innovative, grant-funded forensic behavioral health program serving adults with serious mental illness and co-occurring substance use disorders transitioning from incarceration to community living. The Case Manager provides intensive, community-based behavioral health case management services to adults with serious mental illness and co-occurring substance use disorders who are transitioning from incarceration to community living. Using a trauma-informed, recovery-oriented, and person-centered approach, the Case Manager supports participants throughout critical transition periods, helping them access behavioral health treatment, primary healthcare, housing, benefits, employment supports, and community resources. The position utilizes Critical Time Intervention (CTI) principles and forensic behavioral health practices to improve continuity of care, promote recovery, reduce justice-system involvement, and support successful community reintegration. Note: This position and program require availability of grant funding.

KEY RESPONSIBILITIES

CASELOAD EXPECTATIONS

• Maintain an active caseload of approximately 20-25 participants.
• Provide person-centered, intensive support during pre-release planning and the first six months following community reentry, especially the first 30 days in the community.
• Adjust service intensity based on participant needs and risk factors.

PARTICIPANT ENGAGEMENT AND ASSESSMENT

• Engage individuals prior to release from incarceration and establish therapeutic relationships that support successful reentry.
• Identify barriers to successful community integration and develop individualized service plans.
• Incorporate participant goals, preferences, cultural factors, and recovery objectives into care planning.
• Utilize trauma-informed and motivational interviewing techniques to enhance engagement and retention.

CARE COORDINATION AND CASE MANAGEMENT

• Develop and implement individualized transition and recovery plans.
• Coordinate behavioral health, substance use treatment, primary care, psychiatric, and social service appointments.
• Facilitate linkages to: Medicaid and eligible insurance, Community behavioral health providers, Medication management services, Primary care providers, Housing and supportive housing programs, Employment and vocational services, Benefits and entitlement programs, Financial assistance resources, Peer support and recovery services
• Ensure participants maintain access to essential services during critical transition periods.
• Monitor participant stability and identify emerging behavioral health concerns.
• Support with crisis intervention.

COMMUNITY-BASED SERVICE DELIVERY

• Provide services in community settings, including participant homes, shelters, correctional facilities, treatment programs, hospitals, and other community locations.
• Maintain frequent contact with participants during high-risk transition periods.
• Accompany participants to appointments when clinically indicated.
• Assist participants in developing independent living and community integration skills.
• Support medication adherence and treatment engagement.
• Conduct outreach and re-engagement activities for participants who disengage from services.

CRIMINAL JUSTICE AND SYSTEM COLLABORATION

• Coordinate services with correctional facilities and criminal justice stakeholders.
• Collaborate with probation officers, legal representatives, and community supervision agencies.
• Participate in multidisciplinary meetings regarding participant care and transition planning.
• Support diversion and reentry objectives via consistent communication with system partners.
• Advocate for participant access to services and community supports.

DOCUMENTATION, COMPLIANCE, AND QUALITY

• Complete required documentation within established timeframes.
• Maintain accurate participant records consistent with agency, regulatory, and funding requirements.
• Document assessments, service plans, progress notes, referrals, and outcomes.
• Participate in chart reviews, audits, and quality improvement activities.
• Utilize electronic health record systems and data tracking tools.
• Participate in individual and group supervision.
• Attend required trainings and professional development activities.
• Contribute to program evaluation, and quality improvement initiatives.
• Assist with collection of outcome and performance data to support research objectives.
• Support implementation fidelity to the Pathways to Recovery service model.

PERFORMANCE INDICATORS

• Client engagement and retention rates.
• Successful completion of transition plans.
• Linkage to behavioral health and healthcare services.
• Reduction in hospitalization and crisis service utilization.
• Reduction in criminal justice involvement and recidivism.
• Participant satisfaction and recovery progress.
• Documentation quality and timeliness.

In addition to role responsibilities, each staff member of Community Connections has the following responsibilities as a part of their employment:

• Models and reinforces Community Connections mission to provide behavioral health, residential services, and primary health care coordination for marginalized and disenfranchised women, men, youth, and children living in the District of Columbia, many of whom are coping with challenges including mental illness, addiction, and the aftermath of trauma and abuse.
• Models and reinforces Community Connections values of quality, innovation, respect, equity, and integrity daily.
• Reinforces Community Connection’s commitment to diversity, equity, and inclusion.
• Protects the privacy of our consumer’s protected health information by maintaining compliance with HIPAA and other relevant CC related IT security regulations.
• Completes and stays current on role specific and organizational wide training.
• Performs other duties as assigned on an as-needed basis.

DESIRED KNOWLEDGE & SKILLS

REQUIRED

• Bachelor's degree in Social Work, Psychology, Counseling, Sociology, Criminal Justice, Psychiatric Rehabilitation, Human Services, or a related field.
• Minimum 2 years of experience providing behavioral health, case management, or social services to adults.
• Experience working with individuals with serious mental illness and/or co-occurring substance use disorders.
• Experience working with justice-involved populations.
• Experience providing community-based services.
• Understanding of community resources and behavioral health systems.
• Ability to work independently in community settings.
• Ability to establish effective helping relationships with individuals who have experienced incarceration and behavioral health challenges.
• Effective communication and interdisciplinary collaboration abilities.
• Effective verbal, written, and presentation skills.
• Proficiency with electronic documentation systems.

PREFERRED

• Master's degree in Social Work, Counseling, Psychology, or related field.
• Experience in forensic behavioral health, jail reentry, diversion programs, ACT, community support services, or intensive case management.
• Training in trauma-informed care, motivational interviewing, or recovery-oriented practices.
• Knowledge of serious mental illness, substance use disorders, and recovery principles.
• Knowledge of District of Columbia behavioral health and criminal justice systems.
• Strong clinical, problem-solving, and advocacy skills.
• Strong organizational and documentation skills.

WORKING CONDITIONS AND PHYSICAL REQUIREMENTS

• Extensive community-based work throughout the District of Columbia.
• Services delivered within correctional facilities, homes, shelters, healthcare settings, and community locations.
• Regular local travel required.
• Flexible scheduling, including occasional evening availability to meet participant needs.

COMMUNITY CONNECTIONS OFFERS GREAT BENEFITS INCLUDING:

• Generous PTO, including sick, vacation, and 9 paid holidays
• Medical, Dental, and Vision Insurance
• Medical and Dependent Flexible Spending Accounts
• Agency paid life insurance
• Employee paid Voluntary life insurance
• Employee Assistance Program
• 403(b) Retirement plan
• Educational Assistance
• CEU & Licensure Reimbursement
• Professional and leadership development to include supervision hours for those on track for clinical licensure