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.

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.