AOT Case Manager: Intensive Community Care & Recovery

Home, Hope and Healing Inc. & Aspire Behavioral Health and Counseling; Albany (GA); On-site; USD 42,000 - 58,000; Full time

Job summary

Aspire Behavioral Health and Developmental Disabilities in Georgia seeks an AOT Case Manager to provide intensive, community-based case management to adults with serious mental illness enrolled in Assisted Outpatient Treatment.

You will collaborate with clinicians, peer specialists, medical providers, and the Court Coordinator to coordinate treatment, housing, transportation, benefits, and supports, traveling to homes and facilities to reduce barriers and support recovery.

Qualifications

• Bachelor's degree in social work, psychology, sociology, human services, criminal justice, behavioral health, or a related field preferred. Equivalent education and relevant behavioral health case management experience may be considered.
• Experience providing case management, care coordination, community-based behavioral health services, or services to adults with serious mental illness (SMI) strongly preferred.
• Must demonstrate knowledge of serious mental illness, co-occurring substance use disorders, community behavioral health systems, recovery-oriented services, social determinants of health, community resources, crisis services, and barriers that may interfere with treatment engagement.
• Must possess strong engagement, communication, organizational, documentation, problem-solving, and relationship-building skills and demonstrate the ability to coordinate services across multiple systems.

Responsibilities

• Provide intensive, person-centered case management and care coordination services to individuals enrolled in Aspire BHDD's Assisted Outpatient Treatment Program.
• Work collaboratively with participants, clinicians, peer specialists, medical providers, the Court Coordinator, AOT Project Director, and other members of the multidisciplinary AOT team to support implementation of individualized treatment and recovery plans.
• Complete or assist with comprehensive assessment of participant strengths, needs, barriers, resources, natural supports, and social determinants affecting treatment engagement and community stability.
• Develop, implement, monitor, and update individualized case management goals and interventions in collaboration with the participant and multidisciplinary treatment team.
• Assist participants with accessing and maintaining behavioral health treatment, psychiatric services, medication management, substance use treatment, primary and specialty medical care, peer support, and other clinically appropriate services.
• Coordinate services addressing housing, transportation, food security, financial resources, public benefits, employment, education, identification documents, insurance, legal resources, and other needs affecting participant stability.
• Provide assertive outreach and engagement to participants who experience difficulty maintaining consistent involvement in treatment and community-based services.
• Provide services in community settings whenever appropriate, including participant homes, shelters, hospitals, treatment facilities, community organizations, and other locations necessary to reduce barriers to care.
• Identify barriers contributing to treatment disengagement, psychiatric instability, hospitalization, homelessness, crisis utilization, or other adverse outcomes and work collaboratively with the participant and AOT team to develop strategies to address those barriers.
• Assist participants in developing practical skills necessary for successful community living, including appointment management, transportation planning, medication routines, communication with providers, accessing community resources, budgeting, and development of natural support systems.
• Coordinate transitions between hospitals, crisis stabilization services, residential programs, outpatient providers, and other levels of care to promote continuity of treatment and reduce gaps in services.
• Maintain regular contact with participants based upon individualized need and program expectations and promptly communicate significant changes in participant functioning, engagement, housing, safety, or treatment status to appropriate members of the AOT team.
• Participate in multidisciplinary case staffing and communicate participant strengths, needs, barriers, progress, and service coordination needs to the AOT team.
• Work collaboratively with the AOT Court Coordinator to support coordination of services associated with the participant's AOT civil court order while maintaining appropriate role boundaries between case management and court functions.
• Assist participants in understanding and navigating the behavioral health and community service systems and reinforce information provided by appropriate program and court personnel regarding the AOT process.
• Encourage participant voice, choice, self-advocacy, recovery goals, and active participation in treatment planning to the fullest extent possible.
• Engage family members, natural supports, and significant others when authorized by the participant and clinically appropriate to strengthen community support and treatment engagement.
• Coordinate with hospitals, crisis providers, outpatient providers, housing programs, community organizations, benefits agencies, transportation providers, and other community partners to promote timely access to needed resources.
• Identify emerging participant needs or barriers and communicate them promptly to the multidisciplinary team so that interventions can occur before problems escalated whenever possible.
• Assist with crisis prevention and safety planning in collaboration with clinical staff and connect participants to appropriate crisis resources when increased behavioral health needs are identified.
• Document participant contacts, case management activities, referrals, service coordination, progress, barriers, outcomes, and other required information accurately and within established timeframes.
• Assist with collection and monitoring of required AOT program data and outcome measures related to participant engagement, service utilization, housing, hospitalization, crisis utilization, and other established program outcomes.
• Participate in Continuous Quality Improvement activities and assist the AOT team in identifying service gaps, participant barriers, and opportunities to improve program effectiveness.
• Participate in AOT Management Team activities when requested, multidisciplinary case staffing, program meetings, community partner meetings, required trainings, SAMHSA-related activities as applicable, and other program initiatives.
• Maintain confidentiality, professional boundaries, ethical standards, and compliance with HIPAA, Aspire BHDD policies and procedures, SAMHSA requirements when applicable, applicable Georgia statutes, and other state and federal requirements.
• Perform other duties as assigned.

Skills

Engagement

Communication

Organization

Documentation

Problem-solving

Relationship-building

Travel

Education

Bachelor's degree in social work or related field

Job description

Aspire Behavioral Health and Developmental Disabilities in Georgia seeks an AOT Case Manager to provide intensive, community-based case management to adults with serious mental illness enrolled in Assisted Outpatient Treatment.

You will collaborate with clinicians, peer specialists, medical providers, and the Court Coordinator to coordinate treatment, housing, transportation, benefits, and supports, traveling to homes and facilities to reduce barriers and support recovery.