Transition Case Manager, Community Based Services

About the role

The Transitions Program at CHCI is designed to assist individuals incarcerated and due to be released within 90 days. The goal is to help these individuals set goals before release and coordinate post-release care to reduce recidivism.

Responsibilities

• Work with patients to provide targeted case management and use their individual service plan to accomplish tasks, activities, goals, and objectives that align with their personal goals and long-term plans.
• Act as a patient advocate for individuals facing social determinants of health such as housing insecurity, food insecurity, and economic vulnerability.
• Coordinate patient care internally and externally to ensure the efficient accomplishment of healthcare and social goals.
• Conduct in-person outreach at correctional institutions to enroll eligible participants in the Transitions program.
• Complete and monitor data entry, record keeping, and reporting in CHC EHR daily.
• Conduct and maintain community outreach and collaboration with community organizations and partnerships.
• Obtain and maintain WRNA Training and conduct WRNA Assessments as appropriate for participants.
• Participate in trainings required by Community Health Center and the state of Connecticut.
• Assist with template creation, scheduling, and follow-up for all Transitions patients.
• Work with DOC discharge planners and re-entry counselors to assess patients being released and develop a comprehensive service plan with short and long-term goals and objectives for each individual patient.
• Practice and educate on harm reduction model of care that promotes small, manageable goals and long-term plans.
• Develop policies, procedures, manuals, and trainings as needed for the Transitions Program.
• Affirm compliance with all safety and regulatory requirements for funding.
• Provide support to CHC providers to facilitate continuity of care, treatment adherence, and completion of healthcare goals as needed.
• Participate in all meetings related to Transitions Program and CKP.
• Disseminate information internally at CHC and externally at partner agencies and with community collaborators about services available and how to access them.
• Work with the communications team to develop and update materials that provide information about the Transitions Program for any audience.

Qualifications

• Associate’s degree in human services or related field or high school diploma/GED and adequate experience to replace this.
• Valid Connecticut driver’s license and ability to travel to locations across the state as needed.
• Prior experience working with community agencies and programs.
• Demonstrated ability to work cooperatively with providers and agencies.
• Effective oral and written communication skills.
• Prior experience in providing services to bicultural individuals/families desired.
• Ability to organize, prioritize, and maintain deadlines.
• Working knowledge of the program, its target populations, and additional resources available in the community.
• Current American Red Cross CPR for the Professional Rescuer and AED (CPR/FPR/AED) certification or equivalent.

Primary Contacts

• External: Community Partners - Ongoing
• Internal: Program and Department Staff - Ongoing
• External: Volunteers/Interns - Ongoing
• On-Site Management - Ongoing

Physical Effort/Environment

This position requires some physical exertion, mostly in support of groups in a program area. Work is both remote, office-based, and community-based.

Work Schedule Demands

Full-Time, 40 hours a week with evenings and/or weekends required based on program needs. Ability to travel to locations as deemed necessary.

Communication Skills

Experience with Microsoft Excel, Word, and Outlook. This position is highly involved with staff, providers, clients, colleagues, and community. Strong oral and written skills are required.

Confidentiality of Information

Confidentiality of patient and business information is a requirement. Confidentiality of patient and business information is a requirement. Full access to patient medical records and encounter data. Confidentiality must be maintained according to CHC policies. Responsibility for client data entry. Access to medical system information. Confidential patient correspondence.