Adult Outpatient Community Support Case Manager

East Bay Community Action Program; East Providence (RI); On-site; USD 33,000 - 36,000; Full time

Job summary

East Bay Community Action Program in Barrington, RI seeks an Adult Outpatient Community Support Case Manager to provide wraparound services for adults with complex needs. You will collaborate with the treatment team to coordinate care, connect clients with community resources, and promote stability and independence.

The role emphasizes poverty-reduction supports, medication management, and seamless integration of medical, behavioral, vocational, and substance use services within a CCBCHC

Responsibilities

• Serve as the primary care coordinator for a caseload of SPMI clients, managing health home services including care management, health promotion, and care coordination.
• Assist clients in coordinating and scheduling medical, dental, and specialty appointments with the team, ensuring follow-through on treatment.
• Support medication adherence through scheduling deliveries, pharmacy accompaniment, reminders, and monitoring.
• Facilitate discharge planning and ensure timely follow-up with a licensed provider after inpatient or long-term care stays.
• Provide counseling on disease management, medication purpose, and symptom management aligned with the care team.
• Assist clients in securing daily living necessities such as food, housing, benefits, transportation, and finances.

Job description

Adult Outpatient Community Support Case Manager

Department: Behavioral Health

Employment Type: Full Time

Location: Barrington - OCR

Reporting To: Deidre Graustein

Compensation: $24.00 - $26.00 / hour

Description

The ACT- Adult General Outpatient Community Treatment Specialist provides wraparound case management services to clients who may need additional support and assistance, but whose DLA scores do not warrant placement at a more intensive level of care. The Community Treatment Specialist works collaboratively with clients and the treatment team to identify their needs, connect them with appropriate community resources, coordinate services, and support their overall stability and well-being.

The Community Treatment Specialist is the direct service backbone of EBCAP's high acuity programs delivering wraparound case management, care coordination, and community-based support to adults living with Severe and Persistent Mental Illness (SPMI) and co-occurring disorders. As part of EBCAP's transition to a Certified Community Behavioral Health Clinic (CCBHC) model, the Specialist integrates support across medical, behavioral, vocational, and substance use domains to advance whole-person care.

Key Responsibilities

Care Coordination

• Serve as the primary care coordinator for a caseload of SPMI clients, managing the full scope of health home services including comprehensive care management, care coordination, health promotion, transitional care, and individual and family support.
• Assist clients in coordinating, transporting, accompanying and scheduling medical, dental and specialty appointments in collaboration with the team psychiatrist and nurse; assist with follow-through on treatment based on client needs.
• Support consistent medication adherence through direct assistance including scheduling deliveries, pharmacy accompaniment, phone prompting, medication monitoring, and motivational interviewing as appropriate.
• Assist the hospital liaison and/or team nurses to facilitate discharge planning and ensure clients are seen by a licensed provider within seven (7) days of any inpatient, partial hospitalization, or long-term care facility discharge.
• Provide counseling on chronic disease management, medication purpose, and symptom management aligned with the client's primary and specialty care team's guidance.
• Assist clients in securing and maintaining the necessities of daily life - food, housing, benefits, hygiene, transportation, financial management, and legal advocacy - to support the highest possible level of independence and safety.

Community Support & Advocacy

• Serve as a community liaison and advocate collaborating with schools, landlords, legal guardians, family members, DCYF, OOHA, law enforcement, judicial personnel, healthcare providers, and social service systems.
• Participate as an active member of the multidisciplinary treatment team, contributing to treatment planning meetings, case reviews, and collaborative care coordination.
• Maintain documentation, clinical paperwork, and productivity standards in compliance with CCBHC, BHDDH, Medicaid, Joint Commission, and organizational requirements; support preparation for BHDDH certification site visits.
• Immediately elevate to supervisor any safety concerns, significant declines in client functioning, unsafe or unsanitary living conditions, or other conditions outside acceptable norms.
• Provide assistance with grocery shopping where medically indicated under the direction of the client's medical and/or psychiatric providers (e.g., diabetes management).

Substance Use Support

• Assist clients in identifying triggers, building relapse prevention skills, and strengthening support systems.
• Conduct and supervise urine toxicology screens and breathalyzer tests as directed, including court-ordered supervised screens.
• Discuss the physical, medical, and pharmacological dimensions of substance use and recovery under the guidance of the client's substance use disorder providers.

Vocational Support

• Assess client's educational and vocational interests, capabilities, and readiness to refer to the Vocational Specialist

Organizational Participation

• Actively participate in ongoing education, training, and professional development relevant to the role and client population.