Responsibilities Primary Job Functions: Clinical: • Chart Review and Documentation • Conduct structured reviews of clinical records to assess service utilization, client engagement, and treatment plan compliance. • Document all findings and coordination efforts in the electronic health record using the Care Manager System. • Identify gaps in care, missed services, or follow-up needs and take appropriate action. • Care Coordination • Coordinate physical, behavioral, and social health services across internal programs and external providers. • Facilitate client access to community-based services such as housing, benefits, employment supports, and substance use care. • Ensure referrals are generated, tracked, and closed with appropriate documentation. • Hospital Discharge and Transition Support • Conduct follow-up calls within 24 hours of psychiatric or medical hospital discharges. • Confirm follow-up appointments are scheduled, and discharge instructions are supported and understood. • Notify care team members of transitions and facilitate continuity of care. • Service Monitoring and Engagement • Monitor client attendance at therapy, psychiatry, and medical appointments. • Address patterns of disengagement, such as missed appointments, and initiate outreach or peer support referrals. • Review PHQ-9 and other screening tools to track clinical progress and inform care needs. • Referral and Linkage Management • Create, follow up, and close referrals in the Care Manager System. • Communicate with service providers to confirm that referrals were completed and appointments attended. • Resolve barriers such as transportation, insurance, or documentation needs. • Risk Identification and Response • Monitor client risk levels and report any significant changes to the treatment team. • Support crisis response planning by facilitating communication across care team members and community resources. • Treatment Plan Support • Assist with treatment plan implementation by ensuring services align with identified goals and timelines. • Coordinate updates to the treatment plan as client needs or engagement levels change. • Ongoing Caseload Management • Manage assigned client caseloads, respond to alerts, and complete scheduled reviews as outlined in care protocols. • Participate in team huddles and interdisciplinary case discussions. • Compliance and Reporting • Ensure documentation meets agency, Medicaid, and CCBHC standards. • Maintain timely and accurate entries in line with quality assurance requirements. • Productivity Standard • Care Managers are expected to review an average of 8-10 charts per day as they build familiarity with the process and complete full chart reviews. • Once training is completed and review skills are developed, productivity will increase to 15-20 chart reviews per day, depending on chart complexity, and new patient chart reviews. • Documentation of reviews must be completed daily to ensure timely follow-up and coordination of care. Supervision and Consultation: • Seeks supervision and consultation as needed. • Accepts and employs suggestions for improvement. • Actively works to enhance care management skills Clinical Record Keeping: • Documents interactions with patients and chart reviews. • Documents within Care Manager appropriate follow up and provision of linkage to services. Courteous and respectful attitudes towards patients, visitors, and co-workers: • Treats patients with care, dignity, and compassion. • Respects patient’s privacy and confidentiality. • Is pleasant and cooperative with others. • Personal values don’t inhibit ability to relate and care for others. • Is sensitive to the patient’s needs, expectations, and individual differences. Caseload Management: • Effectively manages caseload based on patient needs and staffs with supervisor regularly. Administrative and Other Related Duties as Assigned: • Actively participates in Performance Improvement activities. • Actively participates in AltaPointe committees as required. • Follows AltaPointe policies and procedures • Attends required in-service training and other workshops, trainings. Qualifications Alabama Licensed Practical Nurse (LPN) in good standing, three years’ experience in nursing is required. Experience working with and accessing community resources; Proficiency in accurate and timely documentation of care coordination in the electronic health record; Demonstrated ability to work with multi-disciplinary teams; Prior work with the special populations as required by CCBHC, preferred. Proficiency in managing multiple priorities. Apply Job!