Care Manager

Job description

Responsibilities 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...