Clinical Case Manager-Team Based Care (31082)

Purpose: (General description and summary) 

The Residential-Clinical Case Manager provides on-site skills training, care coordination, community activities, and groups to participants in our licensed mental health residential facilities, with a focus on skills training to strengthen ADL/IADL skills and care coordination with the treatment team and external providers. The Clinical Case Manager will work within our integrated Team-Based Care model, which brings together peer specialists, residential staff, and the clinical team members to empower individuals in pursuing their mental health goals through collaborative support.  

Environment: 

The Residential-Clinical Case Manager will provide direct care services within our licensed mental health facilities, and in the community with various appointments (i.e. reinstating benefits, accessing care, etc.) and skills training opportunities.  

Accountabilities: (Responsibilities of the job) 

Direct Care / Services & Supports 

• Supports the participant in working toward completion of goals, as defined on the service plan.  

• Coordinates care with external providers and natural supports to support wellness including PCP/medical, payees, ENCC, FD, housing entities, etc. 

• Assists the participant to link to resources to meet basic needs, including Social Security, SNAP, Insurance, Vital records, DMV, Transportation Services, etc.  

• Supports resident in accessing community appointments, including PCP, Dental/Vision, LMP and/or Nursing Appts, as needed 

• Supports resident in working toward fulfillment of their conditional release plan or trial visit. 

• Provides legal skills training, as needed, for counties we have contracts with. 

• Provide skills training around ADL/ADLs and psychosocial skills, including hygiene, budgeting, community inclusion, resource finding, and managing symptoms effectively.  

• Facilitates skills training groups in areas including cooking, art, wellness, or community engagement. 

• Supports in discharge planning through completion of referral paperwork to housing and/or supportive services, when residential services are no longer required.  

• Coordinates transfer of left behind items to storage units or to family.  

Crisis Prevention and Intervention 

• Assesses safety by completing risk assessment and mutual safety plans with the resident and communicates with the team. 

• Works proactively with resident and staff to avoid use of crisis services, demonstrating consistent use of trauma informed care principles 

• Participates in transition planning and ongoing care conferences.  

Administration: 

• Documents all resident contact and consultation with the treatment team and external stakeholders within 72 hours of service delivery in Electronic Health Record, in accordance with policy and Oregon Administrative Rules 

• Participates collaboratively in regular TBC Leadership Meetings and staff meetings 

• Participates in 1:1 supervision bi-weekly to review workload, conceptualization, documentation, and professional development 

• Completes referrals to other levels of care, resources, specialty care, as determined clinically appropriate, etc. 

Other General Expectations: 

• Provides direct care services on-site, in-person due to setting. 

• Attends and positively participate in required meetings. 

• Understands and implement Evidenced Based Practices in all work completed with participants 

• Pursues ongoing development of skills and competencies, with relevant trainings. 

• Follows all corporate policies, procedures, and protocols. 

• Maintains current Oregon Driver’s License, and ability to gain it within 30 days of hire. 

• Follows through