Care Manager (Hybrid-Remote)
About The Position
The Care Manager coordinates physical, behavioral, and social health services for clients across internal programs and external providers. The role includes reviewing clinical records, documenting findings and coordination efforts in the Care Manager System, identifying gaps in care, managing referrals, supporting hospital transitions, monitoring service engagement and risk, and helping implement treatment plans. Care Managers manage assigned caseloads, participate in interdisciplinary discussions, and maintain documentation that meets agency, Medicaid, CCBHC, and quality assurance standards. Care Managers are expected to spend 80–90% of their work time on patient care coordination activities, including chart reviews, outreach, referral management, documentation, and follow-up. During initial training, daily chart-review volume may vary according to learning needs and case complexity. Once fully trained, Care Managers are expected to maintain a consistent workflow aligned with this productivity standard. Daily work includes completing assigned hospital, emergency department, and behavioral health crisis center follow-ups; following up on missed appointments; prioritizing referrals by patient risk; and completing documentation daily. The position requires respectful, compassionate, and confidential interactions with patients, visitors, and coworkers. Care Managers seek supervision and consultation as needed, accept feedback, develop their skills, manage caseloads according to patient needs, participate in performance improvement activities and required committees, follow agency policies, and attend required training. The role is described as hybrid-remote, and a valid driver’s license and reliable transportation may be required depending on program location.
Requirements
- At least 2 years of experience in behavioral health, care coordination, case management, or related healthcare service delivery.
- Strong knowledge of behavioral health systems, including mental health, substance use, and social determinants of health.
- Proficiency navigating and documenting in electronic health records, including coordination systems such as Avatar or an equivalent.
- Experience with treatment planning, interagency coordination, and client engagement.
- Strong organizational and communication skills, including accurate documentation and task follow-up.
- Ability to work independently and as part of an interdisciplinary team.
- Ability to pass background checks and credentialing according to agency standards.
Nice To Haves
- A bachelor’s degree in behavioral health, human services, nursing, public health, or a related field is preferred.
- Experience with high-need populations, including SMI, SED, and SUD, is strongly preferred.
- A valid driver’s license and reliable transportation may be required based on program location.
Responsibilities
- Review clinical records to assess service utilization, client engagement, and treatment-plan compliance, and document findings in the Care Manager System.
- Identify gaps in care, missed services, and follow-up needs, and take appropriate action.
- Coordinate physical, behavioral, and social health services across internal programs and external providers.
- Facilitate access to community-based services, including housing, benefits, employment supports, and substance use care.
- Generate, track, follow up on, and close referrals with appropriate documentation; confirm referral completion and appointment attendance with providers.
- Conduct follow-up calls within 24 hours of psychiatric or medical hospital discharge, confirm follow-up appointments, support understanding of discharge instructions, and notify care team members of transitions.
- Monitor attendance at therapy, psychiatry, and medical appointments; address disengagement through outreach or peer support referrals.
- Review PHQ-9 and other screening tools to track clinical progress and inform care needs.
- Resolve referral barriers such as transportation, insurance, or documentation needs.
- Monitor client risk levels, report significant changes to the treatment team, and support crisis response planning through communication with care team members and community resources.
- Support treatment-plan implementation and coordinate updates as client needs or engagement levels change.
- Manage assigned caseloads, respond to alerts, complete scheduled reviews, and participate in team huddles and interdisciplinary case discussions.
- Complete assigned hospital, emergency department, and behavioral health crisis center follow-ups and all missed-appointment follow-ups; prioritize referrals according to patient risk.
- Complete documentation daily and ensure it meets agency, Medicaid, CCBHC, and quality assurance requirements.
- Seek supervision and consultation as needed, use suggestions for improvement, and enhance care management skills.
- Document patient interactions, chart reviews, follow-up, and linkage to services in the appropriate system.
- Treat patients with dignity, compassion, respect for privacy and confidentiality, and sensitivity to individual needs and differences; interact pleasantly and cooperatively with others.
- Manage caseloads based on patient needs and regularly staff cases with a supervisor.
- Participate in performance improvement activities and AltaPointe committees as required.
- Follow AltaPointe policies and procedures and attend required in-service training, workshops, and other trainings.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
