SUD Case Manager

Position Summary

Neighborhood Health is an innovative network of 11 community health centers in Nashville, Lebanon, and Gallatin, Tennessee. We provide comprehensive primary care, integrated behavioral health, and dental services to almost 30,000 patients. Our patients primarily include immigrants, residents of public housing, individuals experiencing homelessness, and persons living with addiction. As a federally qualified health center, we provide care without regard to health insurance or a patient's ability to pay. We also strive to improve our Patient Centered Medical Home (PCMH) model to ensure all of our patients get the right high-quality care, at the right place, and at the right time.

The SUD Case Manager is responsible for providing comprehensive case management services to patients with substance use disorders receiving care within the integrated primary care setting. The Case Manager will work closely with the care team to ensure that patients receive personalized support, coordinated services, and access to community resources that enhance recovery and overall health outcomes.

Key Responsibilities

Care Coordination

• Conduct pre-screening of prospective patients for MAT and IOP programs. The screening is documented in the EHR.

• Complete intake process for patients accepted into the program

• Complete all intake documents

• Request appropriate records from external providers

• Uploading all relevant documents into the patients' EHR.

• Complete case management needs assessment.

• Provide and document program orientation to SUD patients. Evidenced by documentation in case manager progress notes and signatures on all intake documents.

• Schedule/rescheduling MAT patient appointments.

• Facilitate seamless integration of SUD services into patients' primary care treatment plans.

• Obtain an ROI and request records from all patients' external providers. These records are kept in the patient's EHR.

• Assist patients in establishing PCP care. All patients enrolled in SUD programs must have established PCP care.

• Coordinate medical appointments, therapy appointments, psychosocial services, and behavioral health referrals based on identified needs.

• These referrals and coordination are documented in the patients' individual case mgmt. plan and ongoing case management progress notes in patient's EHR.

• Serve as the primary liaison between patients, healthcare providers, and external agencies to promote continuity of care.

• Maintain and updated list of SUD patients' last external therapy appointment and 12 step meeting attendance.

• The contents of this list align with the patients' case management plan and ongoing progress notes.

Patient Support Services

• Conduct comprehensive patient needs assessments to determine social, economic, and behavioral needs.

• Documented in patients HER

• Assessment is updated at each phase of treatment.

• Informs patients' individualized case management plan.

• Develop individualized case management plans in collaboration with the patient and care team.

• Documented in patients' EHR

• Updated periodically, based on phase of treatment and program guidelines.

• Provide education to patients and families on substance use recovery, available treatments, and community resources.

• Documented in the patients' case management plan and ongoing progress notes.

• Assist patients in the following (documented in case management plans and progress notes):

• Accessing supportive healthcare services

• Applying for health insurance

• Applying for SNAP benefits

• Applying for PAP programs and/or Cover RX

• Accessing self-help meetings and groups

• Complete drug screening and document per Neighborhood Health policy and procedure.

Documentation and Compliance

• Maintain accurate and timely patient records in compliance with HIPAA and program standards.
• Monitor patient progress and update case management plans per program guidelines.
• Ensure documentation adheres to TN BESMART guidelines, Joint Commission standards, and other regulatory requirements.
• Request records from external medical and psychiatric providers and store in patients' EHR.
• Maintain an accurate and up to date program roster, including specific metrics to help advance program goals.
• Maintain an accurate and up to date waiting list for the MAT and IOP programs. This list is submitted to the Director monthly.
• Maintain an accurate and up-to-date referral log for the MAT and IOP programs. This log is submitted to the Director monthly.

Crisis Intervention

• Identify and address potential barriers to treatment, including risk of relapse or crises.
• Provide immediate support during patient crises, including connecting to emergency services or treatment.
• Distribute naloxone and provide overdose prevention education when appropriate.

Collaboration and Outreach

• Participate in interdisciplinary team meetings to discuss patient progress and care coordination strategies.

• Generate list of at-risk patients to be discussed at treatment team meeting in collaboration with program therapist.

• Build relationships with community resources, social service agencies, and support organizations to expand referral networks.

• Engage in community outreach initiatives to promote awareness of SUD services.

• Maintain and regularly update a list of recovery groups that are accepting MAT/OUD patients.

• This list is provided to all patients and documented in the patient's HER

• Develop and maintain a list of in-network therapists/counselors within the TennCare MCO networks who are competent and willing to serve MAT/SUD patients.

• The list is updated and shared with patients at least quarterly. Documented in the patient's EHR.

• An outreach report is submitted to the director monthly, documenting outreach efforts and their results.

• Collaborate with Program Director and business development team to generate outreach materials and plans.

Measurable Expectations:

• Pre-Screening & Intake

• Complete 100% of pre-screening assessments within 48 hours of referral.

• Ensure 100% of accepted patients complete intake documentation within 5 business days of acceptance.

• Upload all relevant intake documents to the EHR within 24 hours of completion.

• Appointment Coordination

• Schedule or reschedule 100% of MAT patient appointments within 48 hours of the request.

• Ensure 90% or more of SUD program patients have an established PCP within 30 days of enrollment.

• Service Referrals & Documentation

• Obtain signed ROIs and request external provider records for 100% of SUD patients within 7 days of intake.

• Document all referrals and case management interactions in the EHR within 24 hours of the encounter.

• Maintain an updated referral log, submitted to the Director monthly.

• Tracking Patient Engagement

• Ensure 90% of patients have an updated case management plan, frequency of update is based on phase in treatment, outlined in the program guidelines.

• Maintain and submit an updated patient roster monthly to the program director with all relevant information completed. This roster to maintain 90% accuracy.

• Needs Assessment & Case Management Plans

• Conduct and document a comprehensive needs assessment for 100% of new patients within 5 business days of intake.

• Update needs assessments at each case management plan update.

• Resource Assistance & Support

• Assist at least 90% of eligible patients with applications for insurance, SNAP, PAP programs, or Cover RX within 30 days of program entry.

• Provide at least 80% of patients with verified access to self-help meetings and groups within 14 days of intake.

• Distribute a MAT-friendly recovery group list to 100% of patients and document in the EHR.

• Drug Screenings & Compliance

• Ensure 100% of required drug screens are completed per clinic policy and results documented in the EHR within 24 hours.

• Patient Records & Reporting

• Maintain 100% compliance with HIPAA and TN BESMART documentation standards.

• Update and submit the program roster, waiting list, and referral logs to the Director monthly.

• Ensure all documentation aligns with Joint Commission standards, subject to internal audits quarterly.

• External Provider Coordination

• Request and store external medical and psychiatric records for 100% of MAT patients within 30 days of intake.

• Relapse Prevention & Emergency Support

• Identify 100% of patients at risk of relapse and document interventions in the case management plan.

• Provide naloxone education and distribute kits to 100% of eligible patients at risk for overdose.

• Interdisciplinary Team Participation

• Attend and actively participate in 90% or more of scheduled interdisciplinary team meetings.

• Generate a list of at risk patients to be discussed at treatment team meetings.

• Community & Provider Outreach

• Maintain and update the list of TennCare MCO network therapists who serve MAT patients quarterly.

• Submit a monthly outreach report documenting outreach efforts, contacts made, and results.

• Engage in at least two community outreach initiatives per quarter to promote MAT services.

Qualifications

Education and Licensure

• Bachelor's degree in Social Work, Psychology, Counseling, or related field required; Master's degree preferred.
• Certification or licensure in Case Management (e.g., CCM, ACM, or equivalent) preferred.
• Certified Peer Recovery Specialist (CPRS) strongly prefeed.

Experience

• 2+ years of experience in case management, behavioral health, or substance use treatment programs.
• Knowledge of MAT, addiction recovery principles, and community resources.

Skills and Abilities

• Strong interpersonal and communication skills, with the ability to establish trust and rapport with diverse populations.
• Proficient in care coordination, patient advocacy, and crisis management.
• Ability to handle sensitive information and maintain patient confidentiality.
• Organized, detail-oriented, and capable of managing multiple tasks.

Preferred Qualifications

• Familiarity with TN BESMART program guidelines and Joint Commission accreditation standards.
• Experience in integrated care or primary care settings.
• Bilingual or multilingual abilities are a plus.

Location: NH Clinic Sites

Reports To: Director of integrated Behavioral Health