Case Manager

POSITION OVERVIEW : The Case Manager serves as a member of the treatment team by working closely with clinical, business development, admissions, nursing and other members of the multi-disciplinary team. The Case Manager is responsible for facilitating recovery by addressing each patient's individual needs and coordinating a thorough aftercare plan that will assist the patient achieve the best possible outcomes through their recovery journey. This includes collaborating with the patient to schedule a mutually agreed aftercare plan of care inclusive of PCP, SUD, MAT and other appointments as well as providing patients with community and other resources that will help ensure their success. The Case Manager serves as a patient advocate, coordinating care with internal and external providers, resources and supports.

The Case Manager engages each patient in their aftercare plan and using teach back method, confirms that the patient and their support system understand the plan and the importance of adhering to the plan. The Case Manager serves as the liaison between the patient and all aftercare providers and resources, ensuring the plan has been established, communicated and confirmed prior to discharge. The Case Manager will also assist patients with any identified outside issues, barriers to accessing care or external stressors that need to be resolved, enabling the patient to focus on treatment (examples: coordination with family for childcare, employer relations, legal concerns, etc.)

The Case Manager works collaboratively with the clinical team to engage, educate and coordinate patient care with the patient, their supports and all external providers to ensure a thorough aftercare plan.

The Case Manager also works closely with external constituents, providing a high level of customer service and satisfaction amongst everyone with whom they interact. Case Managers are responsible for fostering positive relationships between RCA and all stakeholders.

KEY RESPONSIBILITIES:

Obtains applicable signed Release of Information (ROI) forms for all identified providers and resources in the Continued Care Plan (CCP) and other patient resources/supports (Employer/FMLA, Legal, Payer programs, Referral sources, Peer Support, etc.)

Completes a new patient admission assessment and documents in Avatar within 72 hrs. of admission and obtains patient history, needs, and individual preferences to inform the patient's treatment and aftercare plans. Reviews the completed Biopsychosocial assessment to help identify all life domain need and incorporates into the Continued Care Plan to ensure all identified patient needs are addressed during the stay and or in the patient's continuing care plan. The admission assessment should address housing, employment, legal, financial, family and health concerns as well as relapse prevention and other issues that patient requires assistance with.

Documents at minimum, a weekly progress note that includes patient progress toward discharge, discussions of discharge planning and recommended aftercare plan, actual or potential barriers to the plan and patient's engagement in their aftercare plan. Discharge planning should be documented in Avatar by the second week of stay. Initiates and documents all referrals specified in the CCP including contact information and confirms the aftercare plan addresses follow up for substance use, mental health, MAT, Social Determinants of Health and other identified life domains. The individual CCP should be completed in collaboration with the patient and if possible, their support system.

Participates in Multi Disciplinary Team (MDT) meetings and actively contributes to discussion re: recommendations for each individual's aftercare plan, discharge date, services and resources to be included in the aftercare plan and what is needed from other members of the team to help ensure the patient's success with recovery.

Schedules SUD/MAT appointments within 7 days of discharge and post discharge PCP follow up appointments when possible. Appointments and referrals must be documented in Avatar prior to the patient's scheduled discharge.

Ensures effective and timely communication of relevant information to post-discharge providers prior to discharge to facilitate a safe and thorough discharge plan.

Ensures the continued care/discharge plans is solidified 1 week prior to discharge and that a Transitions of Care meeting has been scheduled at least 7 days prior to discharge with the patient, the patient's support system, and the therapist to review the recommended aftercare plan. Confirms patient preferences and barriers to care have been identified and addressed in the plan. Ensures all dates, times, contact information, phone numbers, address, etc.. are included in the CCP to help ensure patient's adherence to the plan. Assesses patient's comprehension of the aftercare plan through verbal confirmation and verifies patient's clear understanding of post-discharge care instructions through teach back.

Follows referent protocols and provides timely clinical updates and other information as requested (with signed ROI).

Follows Payer protocols and facilitates timely patient-payer phone calls, referrals to Payer Peer Support programs and provides other information as per contractual agreements.

Initiates and manages FMLA and Short-term Disability applications as needed, with patient consent. Coordinates with patients and their employers to facilitate benefit processes when applicable. Documents all activities related to FMLA or STD in the patient's EMR. Case Management is responsible for facilitating a weekly Aftercare/Next Steps group meeting for all new patients utilizing standardized RCA agenda and collaterals. Facilitates at least once weekly Guesting to help prepare patients for their aftercare recovery plan and works closely with outpatient staff and Alumni to inform the patient of RCA's outpatient continuum and benefits of continuity of care. Conducts outreach phone calls to patients who leave treatment early or unplanned without a solid discharge plan to attempt to re-engage patient in their recovery plan. Calls should occur within 24 hrs. when possible to help connect them with an outpatient provider and appropriate resources.

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Minimum Qualifications and Skills:

Education: High school diploma, GED, or equivalent is required. A bachelor's degree is preferred. Experience: At least one year of professional experience in the behavioral health and/or substance use treatment field is required. A combination of education and relevant experience will be considered. Knowledge: Must have a strong understanding of health care, the detoxification process, addiction and co-occurring disorders, as well as DSM and ASAM criteria and terminology. Communication: Written: The ability to read, interpret, and write clear, informative text, and to edit work for spelling and grammar. Verbal: The ability to speak clearly and persuasively, listen actively, respond well to questions, and participate effectively in group presentations and team meetings. Technical: Proficiency in Microsoft Programs (Word, Excel, and Outlook).

COMPETENCIES:

Job Knowledge : understands duties and responsibilities of the Case Manager role, understands company mission/values, has knowledge of community resources, ability to network and form working relationships with community providers, willingness to engage in continuing education to keep job knowledge current, ability to utilize and navigate an electronic medical record. Has a good understanding of all levels of care available to patients upon discharge from RCA, including, but not limited to, Sober Living, Extended Care, Outpatient, Psychiatry, etc..

Communication : Excellent communication skills both verbally and in writing; creates accurate and punctual reports; deliver presentations clearly and efficiently; shares information and ideas with others; demonstrates good listening skills; ability to work directly with patients, families, and community providers.

Critical Thinking and Problem Solving Demonstrates exceptional ability to analyze complex patient situations and develop appropriate post-discharge care plans. Anticipates and evaluates potential consequences of decisions to ensure patient safety and well-being. Take decisive action based on thorough analysis and best practices in care transition management ensuring that:

Discharge plans are tailored to individual patient needs, considering their unique circumstances and resources. Collaborates with patients, families, and healthcare teams to make informed mutually agreed upon decisions about post-discharge care. Has the knowledge and skills to balance clinical recommendations with patient preferences to ensure realistic and effective care plans.

Time Management and Organizational Skills : Possesses excellent organizational and time management skills required to work with a diversity of patients with various needs at various stages of life while adhering to all state and federal guidelines.

Decision Making : use effective approaches for choosing a course of action, developing appropriate solutions, and/or reaching conclusions; implement action plans consistent with available facts, constraints, resources, and anticipated consequences; demonstrate confidence in the work done to manage challenging situations.

Collaboration : must be able to work in collaboration with other professionals and leaders across several disciplines, ability to motivate treatment team towards discharge planning when appropriate and obtain recommendations for ongoing treatment.

Work Environment: This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, and filing cabinets. The noise level in the work environment is usually moderate.

Physical Demands: While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands to handle or feel objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, kneel, crouch or crawl. The employee must occasionally lift and/or move objects up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision and the ability to adjust focus.

Travel: Travel is primarily local during the business day, although some out-of-the-area and overnight travel may be required.