SUD Case Manager

POSITION TITLE: Substance Use Disorder Case Manager (SUD CM)

REPORTS TO (TITLE): SUD CM Supervisor

SALARY RANGE: $32.93 - $41.27 hourly DOE

Job Summary: Under the supervision of the SUD Case Management Supervisor and the Program Manager of SUD Services at SRTP (both certified Alcohol & Other Drug Services (AODS) counselors), - the SUD CM is responsible for a specifically assigned caseload of patients and supporting the progress and treatment retention for all SUD/MAT patients generally by providing direct and indirect patient care utilizing individualized treatment planning, psychosocial education and patient support that reflects SUD services which are integrated with primary medical care in an Integrated Care Setting. As a member of the MAT Team (which includes MAT leadership, medical assistants, case managers, and licensed mental health and medical providers), s/he participates in the case management of SUD/MAT patients who may need complex care coordination across multiple life domains and disciplines (medical, dental, mental health, hospital in-patient, and ER visits). The SUD Case Manager also participates in quality improvement activities for numerous health measures related to progress, stability, engagement, and integration with medical and mental health care services. The SUD Case Manager must also carefully collect, organize, and provide SUD Services leadership with data necessary to support development, implementation, grant applications and reports, and quality review and improvement efforts.

Specific Tasks/Duties Include:

• In collaboration with AODS certified counselors, the patient, mental health, and medical providers, assists with meeting the needs of SUD/MAT patients, including participation in 1:1 medically supervised office visits (SUD CM collect meets with patient after the MA and before the provider to obtain current information from the patient, SUD CM then prepares the chart for the provider), warm handoffs, conducting detailed SUD assessments and drafting the related narrative reports, creating and updating thorough treatment plans, education, care coordination, follow-up care, and outside referrals. This work takes place in face-to-face visits, phone meetings, virtual sessions, shared medical visits, and in the Electronic Health Record, and media
• With patients, review all intake documents for thoroughness and accuracy, enter data and scan relevant documents for review in the EHR
• Administers alcohol, drug, socio-economic, anxiety and depression screening tools
• Track and support patient engagement in SUD/MAT care, mental health, and primary care services; use motivational interviewing and shared decision making to identify barriers, strengths and needs to address failure to fully participate in treatment, support prioritizing treatment participation in the face of challenging life circumstances. Seeks to engage patient in a warm and empathic manner, using personal reminder calls and check-ins, and assistance with community transportation when possible.
• Utilizing patient-centered treatment planning, creates and tracks appropriate referrals both in house and within the community
• Updates primary IBH/MH and medical providers with documented, brief summary of patient progress as needed
• Regularly review and report UTOX results to the medical team for interpretation
• Communicate effectively in both written and oral form with medical, dental, and mental health clinicians regarding patient SUD history, treatment planning and patient progress
• Using Electronic Health Records, document patient schedules, communications, progress notes, detailed assessments and narrative reports, and patient facing documentation
• Participate in the schedule to carry the mobile phone which allows patients access to SUD/MAT CM support after hours
• Participate in weekly meetings, including case conference, with MAT Team members, IBH Team, and Campus specific leadership
• In twice monthly meetings, work in close partnership with a licensed MH clinician as a care team partner to support the needs SUD/MAT/IBH patients
• With medical providers, co-facilitate shared medical visits, support group engagement with shared content when indicated to facilitate SMART goal setting. Coordinate with in-house and community pharmacies to ensure workflow efficacy and patient engagement
• Maintain strict adherence to confidentiality laws regarding patient and medical records
• At the request of SRCH leadership, may represent integrated SUD/MAT services in the community and to partnering agencies (SRTP, CenterPoint/DAAC, WRS, Athena House, MADF, Juvenile Hall, Drug Court, Department of Probation, etc.)
• May offer in-person, direct support services to patients who are in custody at the Sonoma County MADF and Juvenile Hall
• Via direct phone contact, act as liaison to local hospitals/ERs to make follow-up appointments for and with patients
• Maintain expertise on subject matter by staying current with required CEUs and educational requirements, rehabilitation tools and information related to substance use disorder, recovery, and MAT for OUD and AUD
• Review jail, court, hospital, ED, inpatient, and crisis stabilization unit reports regarding SUD/MAT patients
• Prepare and then participate in clinical team huddles to provide contextual patient information to medical and mental health providers such as UTOX results, drug use history, current strengths, and stressors
• Will provide services at multiple SRCH Campus locations
• Participate in ongoing training
• Other duties as assigned