Summary
Under the direction of the division supervisor, the Case Manager directly provides high quality care to Neighborhood Service Organization clients by assessing, coordinating, planning, and implementing client‑centered care plans to achieve positive outcomes.
The Case Manager coordinates the interdisciplinary care team (IDT) to maximize client services and benefits, improve client satisfaction, enhance medication adherence, increase access to benefits, secure stable housing, facilitate referrals and entitlements, and reduce emergency room utilization, inpatient admissions, and overall cost of care.
Responsibilities & Duties
Complete case management workflow per process and document timely within the electronic medical record per policy timeframes.
Assess referrals to identify patient and significant other needs, level of intensity, insurance benefits, and other resources.
Make in‑person face‑to‑face encounters (visits) in the client's home, office, or virtual calls to assess current health status and engage the client.
Complete required assessments, case plans or IPOS within required timeframes per policy and procedure.
Collaborate with key individuals to participate in the case plan or IPOS process and continue to involve and communicate as needed to ensure best possible outcomes for the client.
Identify gaps or barriers in the case plan or IPOS treatment plans.
Initiate patient‑focused case plan or IPOS, coordinate services, appointments, and care within required timeframes and as needed.
Refer to outside sources as needed to resolve barriers to access, social determinants of health, or benefits.
Assess the educational needs of clients, families, and health care team members and provide, develop, and implement appropriate teaching strategies or make appropriate referrals.
Provide client education to assist with self‑management as needed based on case plan or IPOS; deliver clinical support to members across a wide array of health topics and conditions.
Monitor client progress toward treatment goals and objectives via ongoing face‑to‑face contact as directed by the Person‑Centered Plan of Service.
Promote high‑quality care through adherence to quality standards for documentation, case management process, and client satisfaction.
Collaborate with specialists, physicians, and medical/clinical directors to coordinate inter‑disciplinary care team and attend necessary meetings to ensure seamless patient care.
Review reporting for trends and data in compliance, medication adherence, outreach failures, ER utilization, and inpatient admissions; provide ongoing monitoring of client.
Ensure client compliance with treatment plan, provider visits, and medication regimen; foster and promote self‑care management and independence in the client’s care.
Facilitate and support client compliance with appointments with provider, clinic, and therapist interactions as needed.
Maintain compliance with all company policies and procedures and applicable MDHHS rules and regulations of DWHIN, NSO, and other entities NSO has entered into a partnership or contracted agreement.
Coordinate with clients to ensure correct identified resources are recommended or obtained within the client’s qualifying benefits or entitlement services.
Consult when appropriate to ensure adequate client caseloads.
Required Qualifications
A bachelor’s degree in a Human Services field.
2 or more years of community‑based experience in mental health as a case manager.
1+ years of recent experience with a mental health/behavioral health clinical environment.
Experience working with children, adolescents, and teen populations requires a total of 3 years working with minors or 24 hours of child‑specific training (CEUs) to be certified by CMHP for MDHHS qualified provider.
Excellent typing skills and ability to navigate a Windows‑based environment, experience using an electronic medical record (EMR).
Ability to navigate through an EMR and utilize Microsoft Products such as Outlook, Teams, Word, and Excel.
Access to secure, high‑speed internet and a dedicated ability to work remote or within a hybrid role, with ability to protect health information and maintain HIPAA.
New graduates in social work are welcome. Limited licensure candidates must be eligible to sit for licensure and pass within 24 months of employment (social work) or a minimum of 5 eligible limited licensure renewals.
Preferred Qualifications
Limited Licensed Social Worker (LLBSW or LLMSW), Licensed Social Worker (LBSW or LMSW).
Certified Case Manager (CCM) or the ability to obtain certification within 24 months of employment.
Background in community‑based care, mental health, behavioral health, homecare, or managed care case management.
Experience/knowledge of discharge planning, resolving disparities in health care, urban populations, atypical home settings, and court‑ordered mental health care.
Experience in utilization review, concurrent review, or coding.
Experience in removing gaps in care, barriers or other disparities in health care.
Hybrid Work Policy
This position offers a hybrid work schedule contingent on meeting productivity standards established by leadership and may be adjusted at any time based on agency needs. Employees may work remotely for a portion of their schedule; however, hybrid work does not permit full days working from home if clients request in‑person appointments in the office or community. Staff are expected to be flexible and prioritize client needs, ensuring timely and appropriate service delivery. During the first 30 days of employment, staff are required to work in the office. This period may be extended based on performance.
Equal Opportunity Employer
NSO is an Equal Opportunity Employer and is committed to excellence through diversity and considers candidates without regard to sex (including pregnancy‑related conditions), genetic information, race, color, weight, height, religion, nation origin, citizenship, age, disability, marital or veteran status, misdemeanor arrest record, sexual orientation, transgender status or gender identity or any other legally protected status.