Transition Case Manager, Community Based Services

Moses/Weitzman Health System•Middletown, CT

1d•Hybrid

About The Position

The Transitions Program is designed to assist individuals who are incarcerated and scheduled for release within 90 days. The program aims to provide systematic support in navigating healthcare and social service systems, setting goals prior to release, and offering post-release care coordination to prevent recidivism. The Case Manager (CM) is responsible for managing a caseload, conducting regular appointments, and supporting the overall operations of the Transitions Program at CHCI. This includes communication with the Department of Corrections (DOC), community partners, and patients. The CM will work closely with the Program Specialist Manager to ensure smooth entry into services for eligible individuals and to meet funder deliverables through efficient data retrieval, documentation, analysis, and monitoring.

Requirements

Associate’s degree in human services or related field or high school diploma/GED and adequate experience to replace this.
Valid Connecticut driver’s license and ability to travel to locations across the state as needed.
Prior experience working with community agencies and programs.
Demonstrates ability to work cooperatively with providers and agencies.
Effective oral and written communication skills.
Ability to organize, prioritize, and maintain deadlines.
Working knowledge of the program, its target populations and additional resources available in the community.
Current American Red Cross CPR for the Professional Rescuer and AED (CPR/FPR/AED) certification or current American Heart Association BLS/AED for Healthcare Providers certification.
Experience with Microsoft Excel, Word, and Outlook.
Strong oral and written skills are required.
Confidentiality of patient and business information is a requirement.
Full access to patient medical records and encounter data.
Confidentiality must be maintained according to CHC policies.
Responsibility for client data entry.
Access to medical system information.
Confidential patient correspondence.

Nice To Haves

Prior experience in providing services to bicultural individuals/families desired.

Responsibilities

Work with patients to provide targeted case management and use their individual service plan to accomplish tasks, activities, goals, and objectives that align with their own personal goals and their long-term plan for success.
Act as a patient advocate for individuals experiencing challenges that include social determinants of health like housing insecurity, food insecurity, and economic vulnerability.
Coordinate patient care internally and externally to ensure the efficient accomplishment of healthcare and social goals.
Conduct in-person outreach at the correctional institute to enroll eligible participants in the Transitions program.
Complete and monitor data entry, record keeping, and reporting.
Complete documentation in CHC EHR daily that provides an overview of encounters and information pertinent to continuity of care and data tracking for each participant.
Conduct and maintain community outreach and collaboration with community organizations and partnerships.
Obtain and maintain WRNA Training and conduct WRNA Assessments as appropriate for participants.
Use WRNA training to interpret results conducted pre-release and use them to assist participants in setting goals.
Participate in any trainings required by Community Health Center and the state of Connecticut.
Assist with template creation, scheduling, and follow up for all Transitions patients.
Work with DOC discharge planners and re-entry counselors to assess patients being released and develop a comprehensive service plan with short and long term goals and objectives for each individual patient.
Practice and educate on harm reduction model of care that will promote the accomplishment of small, manageable goals while also working with patients to empower long term plans that are reasonable and fit their needs.
Work with the Program Specialist Manager to develop policies, procedures, manuals, and trainings as needed for the Transitions Program.
Assist the Program Specialist Manager with all aspects of compliance for all safety and regulatory requirements for funding.
Provide support to CHC providers to facilitate continuity of care, treatment adherence, and completion of healthcare goals as needed.
Actively participate in all meetings related to Transitions Program and CKP.
Disseminate information internally at CHC and externally at partner agencies and with community collaborators about services available and how to access them.
Work with communications team to develop and update materials that provide information about the Transitions Program for any audience.
Performs other related duties as assigned.