• Job Description

  Req#: 24693

  Responsibilities

  Primary Job Functions:

  Clinical:

  • Chart Review and Documentation
    • Conduct structured reviews of clinical records to assess service utilization, client engagement, and treatment plan compliance.
    • Document all findings and coordination efforts in the electronic health record using the Care Manager System.
    • Identify gaps in care, missed services, or follow-up needs and take appropriate action.
  • Care Coordination
    • Coordinate physical, behavioral, and social health services across internal programs and external providers.
    • Facilitate client access to community-based services such as housing, benefits, employment supports, and substance use care.
    • Ensure referrals are generated, tracked, and closed with appropriate documentation.
  • Hospital Discharge and Transition Support
    • Conduct follow-up calls within 24 hours of psychiatric or medical hospital discharges.
    • Confirm follow-up appointments are scheduled, and discharge instructions are supported and understood.
    • Notify care team members of transitions and facilitate continuity of care.
  • Service Monitoring and Engagement
    • Monitor client attendance at therapy, psychiatry, and medical appointments.
    • Address patterns of disengagement, such as missed appointments, and initiate outreach or peer support referrals.
    • Review PHQ-9 and other screening tools to track clinical progress and inform care needs.
  • Referral and Linkage Management
    • Create, follow up, and close referrals in the Care Manager System.
    • Communicate with service providers to confirm that referrals were completed and appointments attended.
    • Resolve barriers such as transportation, insurance, or documentation needs.
  • Risk Identification and Response
    • Monitor client risk levels and report any significant changes to the treatment team.
    • Support crisis response planning by facilitating communication across care team members and community resources.
  • Treatment Plan Support
    • Assist with treatment plan implementation by ensuring services align with identified goals and timelines.
    • Coordinate updates to the treatment plan as client needs or engagement levels change.
  • Ongoing Caseload Management
    • Manage assigned client caseloads, respond to alerts, and complete scheduled reviews as outlined in care protocols.
    • Participate in team huddles and interdisciplinary case discussions.
  • Compliance and Reporting
    • Ensure documentation meets agency, Medicaid, and CCBHC standards.
    • Maintain timely and accurate entries in line with quality assurance requirements.
  • Productivity Standard
    • Care Managers are expected to review an average of 8-10 charts per day as they build familiarity with the process and complete full chart reviews.
    • Once training is completed and review skills are developed, productivity will increase to 15-20 chart reviews per day, depending on chart complexity, and new patient chart reviews.
    • Documentation of reviews must be completed daily to ensure timely follow-up and coordination of care.

  Supervision and Consultation:

  • Seeks supervision and consultation as needed.
  • Accepts and employs suggestions for improvement.
  • Actively works to enhance care management skills

  Clinical Record Keeping:

  • Documents interactions with patients and chart reviews.
  • Documents within Care Manager appropriate follow up and provision of linkage to services.

  Courteous and respectful attitudes towards patients, visitors, and co-workers:

  • Treats patients with care, dignity, and compassion.
  • Respects patient’s privacy and confidentiality.
  • Is pleasant and cooperative with others.
  • Personal values don’t inhibit ability to relate and care for others.
  • Is sensitive to the patient’s needs, expectations, and individual differences.

  Caseload Management:

  • Effectively manages caseload based on patient needs and staffs with supervisor regularly.

  Administrative and Other Related Duties as Assigned:

  • Actively participates in Performance Improvement activities.
  • Actively participates in AltaPointe committees as required.
  • Follows AltaPointe policies and procedures
  • Attends required in-service training and other workshops, trainings.

  Qualifications

  Alabama Licensed Practical Nurse (LPN) in good standing, three years’ experience in nursing is required. Experience working with and accessing community resources; Proficiency in accurate and timely documentation of care coordination in the electronic health record; Demonstrated ability to work with multi-disciplinary teams; Prior work with the special populations as required by CCBHC, preferred. Proficiency in managing multiple priorities.

• About the company

  Call (251) 450-2211 (888) 335-3044 Connect Contact Us > Careers Career Opportunites >

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