Case Manager

Former patients may not be hired at the same location where they were treated until a minimum of one year has elapsed since the completion of their treatment at that location. Former patients may be considered for employment at other locations within a year after treatment, subject to the standard hiring process without compromising ethical standards, patient care, or the reputation of RCA.

About the Role

The Case Manager serves as a member of the treatment team, working closely with clinical, business development, admissions, nursing, and other multidisciplinary team members. The Case Manager facilitates recovery by addressing each patient's individual needs and coordinating a thorough aftercare plan to assist the patient in achieving the best possible outcomes. This includes collaborating with the patient to schedule a mutually agreed-upon aftercare plan of care, inclusive of primary care providers (PCP), substance use disorder (SUD) treatment, medication-assisted treatment (MAT), and other appointments. The Case Manager provides patients with community and other resources to ensure their success, serving as a patient advocate and coordinating care with internal and external providers, resources, and supports.

The Case Manager engages each patient in their aftercare plan, using the teach-back method to confirm understanding and adherence. They serve as the liaison between the patient and all aftercare providers, ensuring the plan is established, communicated, and confirmed prior to discharge. The Case Manager assists patients with external issues, barriers to accessing care, or stressors (e.g., coordination with family for childcare, employer relations, legal concerns) to enable the patient to focus on treatment. They work collaboratively with the clinical team to engage, educate, and coordinate patient care with the patient, their supports, and external providers, ensuring a thorough aftercare plan. The Case Manager also fosters positive relationships between RCA and all stakeholders by providing a high level of customer service.

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 it in Avatar within 72 hours of admission, obtaining patient history, needs, and individual preferences to inform treatment and aftercare plans.
• Reviews the completed Biopsychosocial assessment to identify all life domain needs and incorporates them into the Continued Care Plan to ensure all identified patient needs are addressed during the stay or in the continuing care plan. The admission assessment should address housing, employment, legal, financial, family, and health concerns, as well as relapse prevention and other issues requiring assistance.
• 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 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 discussions regarding 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 team members to ensure patient success in 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 plan 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, and addresses are included in the CCP to help ensure patient adherence to the plan.
• Assesses patient comprehension of the aftercare plan through verbal confirmation and verifies the 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.
• Facilitates a weekly Aftercare/Next Steps group meeting for all new patients utilizing a 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 them in their recovery plan. Calls should occur within 24 hours when possible to connect them with an outpatient provider and appropriate resources.

Requirements

• High school diploma, GED, or equivalent is required.
• A bachelor's degree is preferred.
• 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.
• Strong understanding of healthcare, the detoxification process, addiction and co-occurring disorders, as well as DSM and ASAM criteria and terminology.

Skills

• Communication:
  • Written: Ability to read, interpret, and write clear, informative text, and to edit work for spelling and grammar.
  • Verbal: 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).
• Job Knowledge: Understands duties and responsibilities of the Case Manager role, company mission/values, and knowledge of community resources. Ability to network and form working relationships with community providers, willingness to engage in continuing education, and ability to utilize and navigate an electronic medical record. Good understanding of all levels of care available to patients upon discharge from RCA, including Sober Living, Extended Care, Outpatient, and Psychiatry.
• 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. Takes decisive action based on thorough analysis and best practices in care transition management, ensuring:
  • 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.
  • Balances clinical recommendations with patient preferences to ensure realistic and effective care plans.
• Time Management and Organizational Skills: 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: Uses effective approaches for choosing a course of action, developing appropriate solutions, and/or reaching conclusions. Implements action plans consistent with available facts, constraints, resources, and anticipated consequences. Demonstrates confidence in managing challenging situations.
• Collaboration: Ability to work in collaboration with other professionals and leaders across several disciplines, motivate the treatment team toward 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 uses 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-area and overnight travel may be required.