Case Manager

Essential Duties and Responsibilities

Assessment and Service Planning

• Conduct initial and ongoing needs assessments to identify each client’s strengths, needs, preferences, risks, barriers, and service gaps.

• Develop individualized service plans in collaboration with the client, treatment team, family members, and other authorized supports, when appropriate.

• Establish measurable goals and interventions that address the client’s behavioral health, medical, housing, employment, educational, financial, transportation, and other identified needs.

• Review and update service plans based on the client’s progress, changing needs, preferences, and level of engagement.

Care Coordination and Resource Linkage

• Coordinate services among mental health providers, medical providers, social service agencies, schools, employers, community organizations, and other systems involved in the client’s care.

• Assist clients with accessing community resources, including:

• Housing and shelter services

• Employment and vocational programs

• Educational and training opportunities

• Transportation assistance

• Food and nutritional resources

• Financial assistance and public benefits

• Medical and behavioral health services

• Legal and advocacy resources

• Substance use treatment and recovery supports

• Social, recreational, and community support programs

• Facilitate referrals and follow up with clients and providers to ensure services have been accessed and barriers have been addressed.

• Help clients understand eligibility requirements, application processes, appointments, and documentation required by community agencies and service systems.

• Support clients in coordinating appointments and maintaining engagement with recommended services.

Client Support and Advocacy

• Maintain regular contact with clients through office visits, community visits, telephone, telehealth, or other approved methods.

• Develop supportive professional relationships that encourage client participation, personal responsibility, self-determination, and progress toward established goals.

• Advocate for clients when interacting with healthcare systems, housing agencies, schools, employers, social service organizations, and other community partners.

• Educate clients regarding available services, community resources, treatment options, client rights, and self-advocacy skills.

• Assist clients in identifying and overcoming barriers that interfere with treatment participation or access to services.

• Promote client choice and participation in all decisions regarding services, referrals, and care coordination.

Monitoring and Follow-Up

• Monitor client progress toward service plan goals and document outcomes, referrals, barriers, and follow-up activities.

• Evaluate the effectiveness of referrals and services and modify service plans as needed.

• Communicate significant changes in client functioning, risks, or service needs to the treatment team.

• Support continuity of care during changes in providers, insurance coverage, housing, employment, or level of care.

Crisis Support and Safety

• Recognize and respond appropriately to clients experiencing psychiatric crises, homelessness, abuse, neglect, exploitation, or other urgent safety concerns.

• Provide crisis support within the scope of the position and facilitate referrals to emergency, crisis stabilization, medical, psychiatric, or community resources when appropriate.

• Follow agency procedures regarding mandated reporting and documentation of safety concerns.

• Consult with supervisors and clinical staff regarding clients presenting with elevated risk or complex needs.

Interdisciplinary Collaboration

• Participate in interdisciplinary treatment team meetings, case conferences, and care coordination meetings.

• Communicate professionally with clinicians, medical providers, community partners, clients, families, and other authorized supports.

• Provide timely updates regarding client progress, referrals, barriers, and changing service needs.

• Collaborate with community agencies to improve coordination of services and client outcomes.

Documentation and Compliance

• Maintain accurate, timely, and complete documentation within the electronic health record.

• Complete assessments, service plans, progress notes, referrals, discharge documentation, and other required records according to organizational standards.

• Protect client confidentiality in accordance with the Health Insurance Portability and Accountability Act (HIPAA), 42 C.F.R. Part 2 when applicable, organizational policies, and all applicable federal and state regulations.

• Maintain professional boundaries and comply with ethical, legal, regulatory, payer, and organizational requirements.

• Complete required reports, data collection, quality assurance activities, and administrative responsibilities within established timelines.

• Participate in supervision, staff meetings, trainings, and performance improvement initiatives.

Transition and Discharge Planning

• Assist with discharge planning and transitions of care when clients complete services, relocate, or require a different level of care.

• Coordinate referrals and exchange information with receiving providers following appropriate authorization.

• Educate clients regarding follow-up appointments, community supports, medications, and ongoing resources.

• Document discharge planning activities to promote continuity of care.

Additional Responsibilities

• Maintain current knowledge of behavioral health services, medical resources, public benefits, and community resources available throughout Maryland, Washington, DC, and Virginia.

• Represent The Bridges Wellness Group professionally when interacting with clients, families, referral sources, and community organizations.

• Perform other duties as assigned consistent with the responsibilities of the position and organizational needs.

Working Conditions

• Work may include office-based services, community-based visits, client homes, schools, hospitals, partner agencies, and telehealth coordination depending on client and program needs.

• Local travel throughout Maryland, Washington, DC, and Virginia is required to connect clients with community resources, providers, healthcare systems, and partner organizations.

• The position requires regular interaction with individuals experiencing mental health concerns, housing instability, financial hardship, substance use disorders, family conflict, medical conditions, and other complex psychosocial needs.

• Some evening or weekend hours may be required based on program operations and client needs.

• The position requires the ability to manage changing priorities while maintaining professionalism, flexibility, and sound judgment.

Equal Employment Opportunity

The Bridges Wellness Group is an equal opportunity employer and is committed to maintaining a workplace free from discrimination and harassment. Employment decisions are made without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other status protected by applicable federal, state, or local law.

Position Description Disclaimer

This position description is intended to describe the general nature and level of work performed by an employee assigned to this position. It is not intended to be an exhaustive list of all duties, responsibilities, qualifications, or working conditions associated with the position. The Bridges Wellness Group reserves the right to modify, assign, or remove duties as organizational and program needs evolve.

• Bachelor’s degree in Social Work, Psychology, Human Services, Counseling, Sociology, Criminal Justice, or a related field from an accredited college or university.

• Minimum of one year of experience in case management, behavioral health, healthcare, social services, or community-based support programs preferred.

• Knowledge of behavioral health systems, healthcare resources, public benefit programs, and community resources throughout Maryland, Washington, DC, and Virginia.

• Ability to work effectively with individuals experiencing mental health challenges, housing instability, financial hardship, medical concerns, or other social service needs.

• Strong organizational, communication, advocacy, interpersonal, and problem-solving skills.

• Ability to prioritize multiple responsibilities while maintaining quality and timeliness.

• Ability to establish professional boundaries while developing supportive working relationships with clients.

• Ability to work independently and collaboratively within a multidisciplinary treatment team.

• Proficiency with electronic health records, Microsoft Office applications, email, and other standard office software.

• Ability to maintain confidentiality and comply with applicable ethical, legal, and regulatory standards.

• Valid driver’s license, reliable transportation, and automobile insurance.

Preferred Qualifications

• Experience working in behavioral health, integrated care, community mental health, rehabilitation, healthcare, or substance use treatment settings.

• Knowledge of trauma-informed care, recovery-oriented practice, strengths-based case management, and person-centered service delivery.

• Experience working with underserved, marginalized, and culturally diverse populations.

• Knowledge of Medicaid-funded services, managed care organizations, care coordination, and public benefit programs.

• Experience coordinating services for individuals with co-occurring behavioral health, medical, housing, employment, and social service needs.

• Experience conducting community-based visits and collaborating with multiple service systems.

Core Competencies

• Client engagement and relationship building

• Person-centered and strengths-based service delivery

• Care coordination and resource navigation

• Cultural responsiveness and humility

• Client advocacy and empowerment

• Crisis recognition and intervention

• Professional communication

• Documentation and record management

• Organization and time management

• Critical thinking and problem-solving

• Interdisciplinary collaboration

• Professional ethics and boundaries

• Confidentiality and regulatory compliance

• Adaptability and accountability

Physical Requirements

• Ability to sit, stand, walk, bend, and move between office and community locations throughout the workday.

• Ability to operate computers, telephones, electronic health record systems, and other standard office equipment.

• Ability to communicate effectively in person, by telephone, through telehealth platforms, and in writing.

• Ability to travel throughout Maryland, Washington, DC, and Virginia as required.

• Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of the position.