General Description

Under direction of the Program Manager of Substance Use Services and within federal, state, and local guidelines performs routine case management work. Work involves developing and maintaining contact with clients, client families, and service providers for medical, social, educational, and related service needs while they are enrolled in substance use services.

This position is responsible for overseeing the care of individuals in accordance with HHSC grant and CMBHS documentation standards. The Case Manager facilitates referrals to address both mental and physical health needs, supports recovery from substance use disorders (SUDs), and ensures coordination of services throughout the treatment continuum: pre-entry, during treatment, and post-treatment. Services must be trauma-informed, culturally competent, developmentally appropriate, and community-based when appropriate. The Case Manager provides flexible and individualized support to ensure continuity of care and improved client outcomes. Works under moderate supervision with limited latitude for independent judgment and initiative.

Education, Training, and Experience

• Graduation from an accredited four-year college or university with major coursework in a human services field as required to qualify as a Qualified Mental Health Professional (QMHP) and six (6) months prior experience in a behavioral health or substance use setting preferred.
• Master's Degree in a human services field and previous Crisis or SUD treatment experience preferred.

- Familiarity with HHSC service delivery standards, trauma-informed care practices, and CMBHS documentation preferred.

• English/Spanish bilingual preferred.

Registration, Certification, Licensure, and Other Qualifications

• Must have and maintain a background and criminal history free from any disqualifying offenses as outlined by the Texas Administrative Code (TAC) and the Health and Human Services Commission (HHSC).
• Must possess and maintain a valid driver's license and automobile insurance.
  o Individuals with an out-of-state driver's license must obtain a Texas license within thirty (30) days
• Successful completion of all position-specific and HHSC grant-required trainings within thirty (30) days of employment is required, including Motivational Interviewing, Trauma-Informed Care, and CMBHS documentation procedures.

Knowledge, Skills, and Abilities

- Knowledge of community resources, case management systems, and HHSC program policies and procedures.
- Understanding of CCMS (Comprehensive Case Management Services) structure and ability to deliver services without duplicating other treatment modalities.
- Proficiency in CMBHS for documenting case management progress notes, referrals, and follow-ups.
- Ability to assess client needs and coordinate individualized service plans in alignment with TRR and HHSC fidelity tools.
- Skill in facilitating engagement using Motivational Interviewing to enhance treatment readiness and retention.
- Ability to provide services to priority populations timely and age-appropriately, maintaining accessibility through flexible locations, hours, and days of service.
- Competence in trauma-informed, culturally responsive, and developmentally appropriate service delivery.
- Ability to collaborate with interdisciplinary teams, community partners, and referral agencies (e.g., DFPS, HHSC).
- Ability to make sound clinical and administrative decisions, demonstrate initiative, and maintain professional boundaries.
- Understanding of documentation and audit compliance requirements under HHSC grant and TAC.

Essential Duties

The following list outlines key responsibilities for the position; however, it is not exhaustive and does not encompass all responsibilities. Additional duties may be assigned as needed.

1. Standard of Function and Team Participation

- Attends and participates in all scheduled team meetings, case reviews, and interdisciplinary coordination sessions.
- If a meeting is missed, staff will meet with their supervisor within one week to review missed information.

2. Professionalism and Conduct

- Provides courteous, professional services at all times, maintaining appropriate boundaries and demeanor with clients and partners.
- Demonstrates cultural competence, trauma-informed engagement, and a strengths-based approach in all interactions.

3. Case Management Services

- Provides case management services in alignment with TRR and CCMS standards, including supported housing, employment, budgeting, and life skills training.
- Maintains weekly contact with clients, documents all services in CMBHS, and includes referrals, referral follow-ups, and case management progress notes.
- Ensures access to service coordination that meets client needs through flexible, community-based scheduling.
- Coordinates services to support clients awaiting residential admission and during enrollment in residential care.
- Ensures service plans are collaboratively developed and documented in CMBHS with goals, intended outcomes, and completion/follow-up dates.
- Utilizes Motivational Interviewing and linkage/retention strategies to promote engagement and recovery.
- Coordinates services for dependent children and families to facilitate treatment entry and stability.
- Engages collaboratively with treatment providers to avoid duplication of services while maintaining distinct CCMS functions.

4. Referral and Linkage Services

- Facilitates referrals addressing medical, behavioral, and recovery-related needs and monitors follow-ups to ensure successful linkage.
- Coordinates with community resources such as primary care, recovery housing, employment assistance, and peer recovery supports.
- Ensures that clients discharged from treatment are introduced to recovery support services prior to discharge and documented in CMBHS.

5. Transportation Coordination

- Provides or coordinates transportation for clients and family members as needed for treatment or related services.
- Maintains compliance with Center driving policies, vehicle safety standards, and documentation requirements.

6. Documentation and CMBHS Compliance

- Completes all documentation within two business days and meets or exceeds 95% monthly timeliness.
- Ensures all CMBHS entries include service and referral details, follow-up, and accurate status updates (e.g., Wait List, Active, Discharge).
- Maintains client profiles, financial eligibility, service plans, and assessments per HHSC requirements.
- Completes discharge follow-up between 60-90 days post-discharge as required under TAC.
- Responds to audit findings promptly and ensures full chart compliance.

7. Pre-Entry Services (For Clients on Waitlist for Intensive Residential Treatment)

- Documents all referrals, service plans, and contact attempts weekly in CMBHS with note type "Wait List."
- Develops a service plan using Motivational Interviewing to support engagement and readiness for treatment.
- Coordinates interim services and family supports while clients await placement.
- Collaborates with state and community referral agencies to facilitate admissions.

8. During Treatment Services

- Coordinates CCMS activities with the treatment team to ensure complementary care.
- Documents weekly communication and referrals addressing treatment plan needs.
- Reinforces client strengths and facilitates linkage to post-discharge supports prior to discharge.

9. Post-Treatment Services

- Completes discharge follow-up assessments in CMBHS between 60-90 days after discharge.
- Documents whether the client remains engaged in post-treatment or recovery support services.
- Ensures follow-up data contributes to grant deliverables and outcome reporting.

10. Crisis and Zero Suicide Initiative

a. Supports individuals in crisis by connecting them promptly to appropriate services (MCOT, Crisis Prevention, etc.).
b. Remains with individuals when safe until crisis staff arrive.
c. Participates in post-crisis debriefings and ensures compliance with HHSC safety and reporting standards.

11. Additional Duties

- Completes assignments in a timely manner.
- Participates in required grant trainings, fidelity reviews, and quality improvement activities.
- Submits required deliverables in alignment with HHSC and Center grant reporting schedules.