Re-Entry Case Manager

Casa Esperanza•Boston, MA

159d•$52,000 - $55,000•Onsite

About The Position

Casa Esperanza seeks a dynamic, energetic individual who is passionate about delivering recovery and wellness-oriented community-based case management and care coordination for people living with addiction, mental health, and co-occurring disorders as part of our Casa Community Support Program. The Casa Community Support Program (CSP) addresses the health-related social needs of individuals living with substance use and co-occurring behavioral health disorders to help them thrive and live successfully in the community. Reentry Case Management delivers intensive case management, including assertive outreach, service coordination, monitoring, and follow-up, to individuals who are justice-involved, including reentry, parole, and/or probation. The Reentry Case Manager works with the CasaCare multidisciplinary team to provide care coordination for individuals as part of the CasaCare integrated care model, which includes primary care, mental health, and addiction treatment. The Reentry Case Manager must be able to initiate and complete work independently to fulfill the responsibilities of the job and work collaboratively with all members of the care team. With a career at Casa, you will be joining a vibrant team of dedicated and talented people. While there may be opportunities for occasional work from home, this is primarily an in-person, community-based role that requires travel, providing transportation for patients, and in-office time.

Requirements

Bilingual Spanish/English require
Bachelor’s degree or three years of relevant work experience, or lived experience
Knowledge of SUD and mental health treatment, the recovery process and resources, supported employment and/or vocational and education services, housing supports, and HIV services
Experience doing outreach and engagement with individuals with a history of or at risk for justice involvement, HIV, addiction, mental illness, trauma and violence
Able to work weekends and evenings, as needed
Familiar with social, health and cultural issues specific to the Latine population
Ability to work as a team member and independently
Understanding of harm reduction principles and techniques
Strong verbal and written communication skills
Strong interpersonal skills and crisis management skills
Be in good standing with their board of professional licensure, as applicable
Computer skills, minimum Microsoft Word
Have either a Community Health Worker (CHW) certification or a Licensed Alcohol and Drug Counselor (LADC), or willingness to acquire one within one year of employment

Responsibilities

Deliver services in 1) a linguistically appropriate and culturally competent manner that embraces the diversity of people's identities, including racial, ethnic, gender/gender identity, sex, sexual orientation, and disability, including intellectual disability; and 2) an integrated manner that meets the needs of individuals with co-occurring substance use disorder and mental health conditions, honoring their chosen pathway to ending homelessness.
If the client is coming from a 24-hour behavioral health level of care, including inpatient and diversionary providers, the program will participate, as appropriate, in member discharge planning at the referring provider.
Conduct biopsychosocial assessments for each client, including comprehensive assessments of health-related social needs, including those related to justice involvement, and generate individualized service plans that reflect each client’s unique strengths (including community and family strengths), needs, abilities, preferences, motivation, and readiness, as appropriate.
Conduct discharge planning upon admission of the client, which includes social support, care providers, service agencies, parole or probation staff if applicable, crisis prevention, and safety planning.
Assume primary case management responsibilities for clients after assessment and maintain a caseload of 20 individuals.
Provide skill-building and wellness education, both individually and in group settings, regarding substance abuse, mental health, HIV, and other health literacy and wellness information to clients and their family members.
Connect clients to SUD and mental health treatment, recovery support services, supported employment and/or vocational and education services, housing supports, and HIV services at Casa Esperanza and at other agencies across Greater Boston.
Provide comprehensive coordination across Casa programs and externally across the network of services.
Provide one-to-one client orientation to support client adherence to the goals in the Individual Service Plan.
Provide services that actively support the reentry process, including 1) ensuring that the service plan supports the client’s probation and parole supervision plan, as applicable, and 2) addressing barriers to preventing recidivism in the service plan goals, including interventions and strategies for developing alternative behaviors.
Support patients in securing appropriate services such as medical, dental, benefits programs such as SSI, HDAP, and SNAP, housing, financial, legal, education, training, employment, life skills, peer support, family support, and other services.
Coordinate with the Housing Case Manager to support with the housing search process, including applications for supportive or transitional housing.
Provide access to peer support and peer-reinforced group interventions.
Work closely with the Multi-Disciplinary Team (MDT) on all aspects of care planning, including assessments, transition, and discharge planning to engage, retain, and monitor clients in care.
Conduct intensive outreach efforts to reengage or maintain engagement with clients, including at least four instances of case-related work per client over a 30-day period, at least one of which must be a direct connection with the client.
Work closely with the Patient Access teams to coordinate enrolling clients into reentry services.
Document the comprehensive needs assessment and all subsequent client encounters and other data as required and maintain up-to-date client records in Casa’s electronic health record, Evolv.
Update the comprehensive needs assessment with the client quarterly in Evolv.
Document individualized service plans. Update service plans at least every 12 months.
Document discharge planning upon admission and provide a written copy of the plan to the client (as well as individuals or organizations involved with the client’s ongoing care) upon discharge.
Ensure all data collection and reporting requirements are completed within the time frames specified in the CSP Agreement.
Attend biweekly supervision.
Write and submit all reporting as required by payors, regulators, and Casa’s internal Practice Management and Quality teams in a timely manner.
Attend all relevant case conferences and staff meetings, including but not limited to Multi-Disciplinary Team, Recovery Support Services, and Office-Based Addiction Treatment.