General Characteristics of Duties:

Provide care management to adults focusing on strengths of individuals and families. Care management services assist individuals in gaining access to and maximizing the benefit of needed medical, social, educational and other support services. Care Management services as outlined in the TN Health Link model perform six distinct activities: Comprehensive Care Management, Care Coordination, Referral to Social Supports, Patient and Family Support, Transitional Care and Health Promotion. Care Management as a service is provided both at the office and within the community as appropriate to the needs being addressed.

1. – Initiate, complete, update, and monitor the progress of a comprehensive person-centered care plan (as needed).

2. – Participate in the patient’s physical health treatment plan as developed by their primary care provider as necessary. Support scheduling and reduce barriers to adherence for medical and behavioral health appointments. Proactive outreach and follow up with primary care and behavioral health providers.

3. – Identify and facilitate access to community supports (food, shelter, clothing, employment, legal, entitlements and all other resources). Communicate patient needs to community partners. Provide information and assistance in accessing services.

4. – Provide high-touch in-person support to ensure treatment and medication adherence. Provide caregiver counseling and training. Identify resources to assist individuals and family supporters.

5. – Provide additional high touch support in crisis situations. Participate in development of discharge plan for each hospitalization. Develop a systemic protocol to assure timely access to follow-up care post discharge. Establish relationships with other treatment settings. Communicate and provide education.

6. – Education the patient and his/her family on independent living skills with attainable increasingly aspirational goals.

Other Duties:

1. Reports / Record keeping

2. Engagement

● Treat consumers with respect as individuals.

● Connect in a positive manner with consumers, family members and other natural supports.

● Solicit consumer opinions and input.

● Listen and respond with respect.

3. Promote the Care Management Team

● Actively participate in team process and utilize team resources.

● Meet with team on scheduled staff meetings and discuss any concerns regarding working with consumer, etc.

● Employ good communication skills (listening, reflecting, role model, etc.)

● Report and share information promptly with doctor, team, and others, as appropriate.

4. Re-entry Care Manager

● Provide support and education to participants of the Recovery to Re-Entry program.

● Meet with clients weekly to discuss any concerns, work towards re-entry goals, and assist in any recovery needs. Provide information and resources for those with Opioid Use Disorder who are enrolled in the Re-Entry Program.

● Provide education to support participants with understanding Opioid Use Disorder (i.e. worksheets, educational materials, and homework) to help them actively participate in their recovery.

● Provide updates to referrals in the Judicial System

● Work with participants to enhance re-entry into the community.

EDUCATION / EXPERIENCE

Must have a Bachelor’s degree in a health-related field of counseling, psychology, social work or other behavioral sciences.

Job Type: Full-time

Pay: From $38,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Schedule:

• 8 hour shift
• Day shift

Education:

• Bachelor's (Required)

Work Location: In person