Targeted Case Manager

Job Description:

As part of the Certified Community Behavioral Health Clinic (CCBHC) model, the Targeted Case Manager (TCM) provides short-term, community-based case management services to individuals with behavioral health needs who are also experiencing unmet health-related social needs (HRSNs) such as housing instability, food insecurity, transportation barriers, and safety concerns.

The TCM identifies HRSNs and connects eligible individuals to appropriate resources and services available through the Social Care Network (SCN) and other community-based resources. Using the CMS Health-Related Social Needs (HRSN) Abbreviated Screening Tool, the TCM engages individuals in their communities, where they live, receive care, or access resources, to identify social care needs and facilitate appropriate referrals and linkages.

The TCM will utilize the Unite Us platform to support Social Care Network referrals, track connections to services, and ensure accurate and timely documentation of HRSN screening, referrals, follow-up, and outcomes.

Services are delivered throughout Clinton County, with a focus on communities where Medicaid members and individuals with behavioral health challenges are most concentrated. This is a flexible, field-based role emphasizing brief, targeted interventions, often a single encounter or short-term follow-up, to reduce barriers to health, wellness, and treatment engagement.

Key Responsibilities

· Provide brief, community-based case management services to individuals with behavioral health needs who screen positive for health-related social needs (HRSNs).

· Administer the CMS HRSN Abbreviated Screening Tool to identify needs related to housing, food, transportation, utilities, safety, and other social determinants that may impact an individual's health and behavioral health outcomes.

· Connect eligible individuals with services and resources available through the Social Care Network (SCN), as well as other appropriate community-based providers and resources.

· Utilize the Unite Us platform for Social Care Network referrals, care coordination, referral tracking, follow-up, and accurate and timely documentation of services and outcomes.

· Facilitate closed-loop referrals whenever possible by monitoring referral status, identifying barriers to successful connection, and following up with individuals and community providers as appropriate.

· Connect individuals to immediate community resources for basic needs, benefits, healthcare, behavioral health treatment, recovery supports, housing, food, transportation, and other identified needs, often through a single contact or brief period of follow-up.

· Provide transportation, outreach, and community-based support services to reduce barriers to care and connect individuals with treatment, recovery, medical, social, and community resources as needed.

· Coordinate with the CCBHC's clinical, care coordination, peer support, and other interdisciplinary team members to support integrated, person-centered care.

· Build and maintain relationships with Social Care Network partners, community-based organizations, healthcare providers, social service agencies, and other referral partners throughout Clinton County.

· Conduct outreach in community settings to identify and engage individuals who may benefit from HRSN screening, Social Care Network services, behavioral health treatment, or other community supports.

· Deliver culturally responsive, person-centered, recovery-oriented, and trauma-informed services consistent with CCBHC standards and practices.

· Maintain timely and accurate documentation of screenings, contacts, referrals, services, follow-up activities, and outcomes in the Unite Us platform and the agency's electronic health record, as required.

· Communicate and coordinate with community providers to reduce duplication of services and support continuity of care.

· Maintain client confidentiality and comply with all applicable agency, state, federal, Medicaid, HIPAA, and 42 CFR Part 2 requirements.

· Participate in supervision, team meetings, case consultation, training, community outreach activities, and quality improvement initiatives as assigned.

Qualifications

• Bachelor's degree in Human Services, Social Work, Psychology, Counseling, Sociology, or a related human services field required.
• Prior experience with care coordination, case management, community-based services, behavioral health, social services, or a related setting preferred.
• Experience working with individuals with mental health, substance use, or other behavioral health needs is preferred.
• Knowledge of community resources and social service systems, particularly within Clinton County and the surrounding region, is preferred.
• Ability to engage individuals in community-based settings and work effectively with diverse populations using a person-centered, recovery-oriented, and trauma-informed approach.
• Strong communication, organizational, and documentation skills, including the ability to coordinate with multiple community providers and service systems.
• Ability to work independently in a flexible, field-based role while collaborating effectively as part of an interdisciplinary team.
• Basic computer proficiency and ability to learn and effectively utilize electronic health records, referral platforms, and other required technology, including Unite Us.
• Valid driver's license and ability to travel throughout Clinton County as required to provide outreach, transportation, and community-based services.

Champlain Valley Family Center is an Equal Opportunity Employer and values diversity. We welcome applications from individuals of all backgrounds, including those with lived experience in behavioral health recovery.

Job Type: Full-time

Pay: $22.00 - $26.00 per hour

Benefits:

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