AOT CASE MANAGER (GLEN BURNIE, MD)

Core Responsibilities

• Conduct comprehensive biopsychosocial needs assessments for all assigned AOT participants upon enrollment and at minimum every six months thereafter, in compliance with COMAR 10.21.20 treatment planning requirements.
• Develop, implement, monitor, and update individualized service plans (ISPs) in collaboration with participants, treatment team members, and court personnel, ensuring plans are person-centered, strengths-based, and goal-oriented.
• Conduct regular community outreach and home visits to engage and monitor participants, including individuals who are homeless, unstably housed, or otherwise difficult to reach.
• Facilitate enrollment in and maintenance of public benefits including SSI, SSDI, Maryland Medicaid, HealthChoice, and other entitlement programs to support long-term financial stability and healthcare access.
• Provide housing navigation services, including referrals to emergency shelters, transitional housing, supportive housing programs, and coordination with Maryland’s Housing and Community Development resources.
• Monitor and document each participant’s compliance with all components of their court-ordered AOT treatment plan, including psychiatric appointments, medication adherence, and community service engagement, in accordance with COMAR 10.21.20.
• Career with AOT Psychiatrist, primary care physicians, substance use treatment providers, and other medical and behavioral health clinicians to ensure integrated service delivery consistent with COMAR 10.21.17 community-based service standards.
• Respond to and document crisis situations, implementing individualized crisis plans and coordinating with Mobile Crisis Teams, emergency departments, and psychiatric inpatient facilities as clinically appropriate.
• Prepare written court compliance reports for submission to the Court Liaison prior to all scheduled AOT hearings, accurately reflecting participant progress, challenges, and engagement status.
• Maintain timely, complete, and accurate case notes, service plans, and all required documentation in the agency electronic health record (EHR), consistent with Maryland Medicaid billing standards and COMAR 10.21.20 documentation requirements.
• Transport or coordinate transportation for participants to psychiatric appointments, court hearings, and community services as needed, adhering to Lead4Life vehicle safety and participant confidentiality policies.
• Facilitate warm referrals and transitions to community resources, peer support services, vocational rehabilitation, and educational programs that promote long-term recovery and community integration.
• Participate in weekly interdisciplinary team meetings, individual clinical supervision, and required agency training to ensure continued professional development and program quality.
• Aid participants in developing natural support networks and connecting with family members, when appropriate and with participant consent, to promote durable community recovery.
• Comply with all HIPAA, Maryland Health-General Article §10-809, and Lead4Life confidentiality policies in all communications involving participant information with courts, providers, and community partners.

Requirements

• Bachelor’s degree in Social Work, Psychology, Counseling, or a human services-related field required
• Licensed Master Social Worker (LMSW) in the State of Maryland preferred
• Minimum of two (2) years of experience in case management, behavioral health services, or a closely related human services field required
• Maryland Certified Peer Recovery Specialist (CPRS) or Mental Health Rehabilitation Specialist (MHRS) certification preferred
• Knowledge of Maryland public benefits systems (Medicaid, SSI/SSDI, HealthChoice) strongly preferred
• Experience working with individuals with serious mental illness (SMI) in community-based settings preferred
• Proficiency in electronic health record (EHR) systems required
• Bilingual (English/Spanish) preferred

Additional Requirements

• Valid driver’s license and insurable driving record required
• Must pass pre-employment drug screening
• Must pass criminal background check (CJIS/FBI) per Maryland law
• Must pass Child Protective Services (CPS) clearance
• TB test or health screening as required by program
• Current CPR/First Aid certification (or willingness to obtain within 30 days of hire)
• Physical examination clearance if role involves direct client transport