Care Manager

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Responsibilities

• 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 dedicate the majority of their workday to direct patient care coordination activities.
• Care Managers will spend 80-90% of their time on patient care coordination, which includes chart reviews, outreach attempts, care coordination tasks, referral management, documentation, and follow-up.
• During the initial training period, Care Managers will focus on building proficiency with workflows, documentation standards, and chart review processes.
• During this time, the number of charts reviewed per day may vary based on learning needs and case complexity.
• Once fully trained and able to conduct efficient and thorough chart reviews, Care Managers will be expected to maintain a consistent workflow that aligns with spending 80-90% of time on patient care coordination tasks.
• Each day, Care Managers are expected to: Fully work all Hospital/ED/BHCC follow-ups assigned to them.
• Complete all missed appointment follow ups.
• Work referrals in order of patient risk, ensuring high risk patients are prioritized, followed by moderate-high risk, and then moderate- and low-risk referrals.
• Documentation must be completed daily to support timely follow-up, continuity, and closed-loop care coordination.
• 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.
• Is sensitive to the patient’s needs, expectations, and individual differences.
• 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.

Requirements

• Personal values don’t inhibit ability to relate and care for others.
• Education: Bachelor’s degree in a behavioral health, human services, nursing, public health, or related field is preferred -or- High School diploma or equivalent and 4 years of experience in behavioral health, care coordination, case management, or related healthcare service delivery.
• Minimum of 2 years of experience in behavioral health, care coordination, case management, or related healthcare service delivery.
• Experience with high-need populations (SMI, SED, SUD) strongly preferred.
• Strong knowledge of behavioral health systems, including mental health, substance use, and social determinants of health.
• Proficiency in navigating and documenting within electronic health records (EHR), including coordination systems like Avatar or equivalent.
• Experience with treatment planning, interagency coordination, and client engagement.
• Strong organizational and communication skills, including ability to document accurately and follow up on tasks.
• Ability to work independently and as part of an interdisciplinary team.
• Valid driver’s license and reliable transportation may be required based on program location.
• Ability to pass background checks and credentialing per agency standards.

This week, AltaPointe is organizing a hiring event. Explore our job opportunities at AltaPointe.org, submit your online application, and then join us for Open Interviews to meet with a recruiter in person! Experience is not required, as we have positions available at all levels. Tuesday, November 3rd– 3030 Knollwood Drive in Mobile from 10 am – 2 pm.