LPN Care Manager (Hybrid Remote) (Baldwin, Mobile & Washington Counties, AL)

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 patients privacy and confidentiality.
• Is pleasant and cooperative with others.
• Personal values dont inhibit ability to relate and care for others.
• Is sensitive to the patients 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.

Minimum Qualifications:

Education:

Bachelors degree in a behavioral health human services nursing public health or related field is preferred -or- High School diploma or equivalent and 4 years of experience in behavioral health care coordination case management or related healthcare service delivery.

Experience:

Minimum of 2 years of experience in behavioral health care coordination case management or related healthcare service delivery. Experience with high-need populations (SMI SED SUD) strongly preferred.

Skills and Competencies:

• Strong knowledge of behavioral health systems including mental health substance use and social determinants of health.
• Proficiency in navigating and documenting within electronic health records (EHR) including coordination systems like Avatar or equivalent.
• Experience with treatment planning interagency coordination and client engagement.
• Strong organizational and communication skills including ability to document accurately and follow up on tasks.
• Ability to work independently and as part of an interdisciplinary team.

Other Requirements:

• Valid drivers license and reliable transportation may be required based on program location.
• Ability to pass background checks and credentialing per agency standards.