Case Manager (Prince William/Fredericksburg)

About the role

Brain Injury Services (BIS) seeks a full-time Brain Injury Case Manager to serve clients in Prince William County/Fredericksburg area. Under supervision of the Senior Manager of Case Management Services, the Case Manager provides community-based case management to adults and children with acquired brain injury and their families in the Northern Virginia region. The role includes long-term case management, public awareness, and uses a community-based case management model.

Responsibilities

• Adhere to professional standards, federal and local requirements, and MCO regulations.
• Obtain information and make referrals for appropriate services, including TCM-related referrals and general community service referrals.
• Conduct a comprehensive intake evaluation, completing all designated documentation and obtaining necessary medical records.
• Complete required paperwork for Medicaid TCM services: service authorizations, assessments, evaluations, reviews, billing, reporting.
• Perform a thorough client assessment including strengths/weaknesses, family/community support, needs assessment per Adult Brain Injury Case Management Policy and Procedure Manual, and assessment of existing resources and service gaps within 45 days of case opening.
• Obtain appropriate releases, understand confidentiality laws, and uphold them.
• Provide public education and awareness on brain injury prevention, identifying children/adolescents with brain injury, and supporting transition back to school and home community.
• Travel to clients' homes and communities; participate in discharge planning teams at children’s facilities and rehab centers (e.g., Cumberland Hospital, Kluge Children’s Rehab Center, NRH Pediatric Program, Kennedy‑Krieger Institute).
• Determine when maximal functioning has been achieved and coordinate fading of outside services such as life skills training/tutoring.
• Maintain orderly charts and complete all paperwork per Policy and Procedure Manual.
• Establish a therapeutic relationship with clients, families, and community providers.
• Support clients in developing goals and plans based on the needs assessment; complete an Individualized Service Plan (ISP) and provide a written copy.
• Review the ISP every 90 days per MCO rules; obtain client signatures for consent.
• Identify, coordinate, and monitor goal‑directed community services per client plans.
• Maintain in‑person and/or virtual contact with active clients/families at least monthly; quarterly contact with follow‑along clients.
• Negotiate for services professionally in clients’ communities.
• Maintain a confidential home office with reliable internet for remote work; otherwise work from the office.
• Manage caseload: up to 30 active clients and no more than 15 follow‑along for full‑time staff; adjusted caseloads for reduced hours (30‑35 hrs/week up to 26 active) and part‑time (≤20 hrs up to 20 clients).
• Understand the Vendor Contract budget and prioritize service payments based on need, financial eligibility, and resource availability.
• Understand the Vendor Contract for various MCOs and their specific requirements.
• Provide education to clients, families, and