Targeted Case Manager; 4176-202-N

1623 Flatbush Ave, Brooklyn, NY 11210, USA Req #2455
Thursday, July 29, 2021


Under the direct supervision of the Clinical Director, the Targeted Case Manager (TCM) will play a pivotal role within the integrated care ecosystem of the Certified Community Behavioral Health Clinic (CCBHC).  Under the SAMHSA grant, the TCM will be part of a specialized team embedded in the CCBHC, targeting services for a high-risk behavioral health population being served under CCNS. The TCM team will adhere to specific SAMHSA regulations and requirements regarding the frequency, scope and duration for working with clients under a Critical Time Intervention model. The CCBHC is based on an initiative to expand Americans’ access to mental health and addiction care in community-based settings. CCBHCs are responsible for providing the following types of services: crisis mental health services; screening, assessment and diagnosis, including risk assessment; patient-centered treatment planning; outpatient mental health and substance use services; primary care screening and monitoring of key health indicators/health risk; targeted case management; psychiatric rehabilitation services; peer support and family supports; intensive, community-based mental health care for members of the armed forces and veterans.


Under the CCBHC model, the Targeted Case Manager (TCM) will work in conjunction with the CCNS CCBHC clinics and will coordinate care across settings and providers to ensure seamless transitions for clients across the full spectrum of health services, including acute, chronic, and behavioral health needs. Duties of the TCM focus on the integration of the care team to serve the client in any appropriate need-based area, including mental health, medical issues, social determinants of health, substance use issues, psychosocial needs, food insecurity, housing instability. The TCM is responsible for high quality targeted case management services that will assist individuals in sustaining recovery, and gaining access to needed medical, social, legal, educational, and other services and supports.  



  • In conjunction with interdisciplinary team, is accountable for engaging and retaining client in care, arranging for the continuous provision of services, supporting adherence to treatment recommendations, monitoring and evaluating client needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care.
  • Provide direct care, face-to-face services to clients in the home and community.
  • Outreach via phone to clients between visits (check on self-care, medication fills, treatment plan, schedules visits, tests/follow-up); monitors that the client completes post-visit follow-up (fill prescriptions, make appointments).
  • Conduct comprehensive assessments to develop a person-centered and recovery-oriented Care Plan.
  • Identifies potential barriers to successful care and resolutions to those barriers as part of person-centered care planning.
  • Coordinate care across the spectrum of health services, including access to high-quality physical health (both acute and chronic) and behavioral health care, as well as social services, housing, educational systems, entitlements/benefits and employment opportunities as necessary to facilitate wellness and recovery of the whole person.
  • In collaboration with interdisciplinary team, clients, their family and/or caregivers, and other service providers, develops, manages and coordinates a comprehensive individualized person-centered care plan that coordinates and integrates the continuum of medical, behavioral health services, rehabilitative, long term care and social service needs and clearly identifies the primary care physician/nurse practitioner, specialists, behavioral health care providers, care manager and other providers directly involved in the individual’s care.
  • Ensure the availability of priority appointments for CCBHC clients to treatment services including physical, psychiatric, and substance abuse within their health provider network to avoid unnecessary, inappropriate utilization of emergency room and inpatient hospital services.
  • Assist clients and families of children and adolescents in obtaining appointments and keeping the appointment when there is a referral to an outside provider, subject to privacy and confidentiality requirements and consistent with consumer preference and need.
  • Promotes evidence based wellness and prevention by linking CCBHC clients with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other medical services based on individual physical needs and preferences.
  • Aid CCBHC clients in identifying the primary care physician and multidisciplinary teams of medical, mental health, chemical dependency treatment providers, social workers, nurse’s nutritionists/dieticians, pharmacists, outreach workers including peer specialists and other care providers to assure that enrollees receive needed medical, behavioral, and social services in accordance with a plan of care.
  • Refer CCBHC clients to peer supports, support groups, and self-care programs to increase client’s and caregivers knowledge about the individual’s diseases;  promote client’s engagement and self-management capabilities in their participation in care plan development and decision making.
  • Assist clients in obtaining appointments and keeping the appointment (escort as needed) when there is a referral to an outside provider.
  • Track and shares CCBHC clients’ information and care needs across providers  by utilizing electronic databases  and monitors outcomes and initiates changes in care, as necessary, to address an individual’s needs.  
  • Complete progress notes, incident reports, and other required documentation and maintain accurate recordings in electronic case files in a requested timely fashion.
  • Verify CCBHC clients receive test results; monitor medical directives follow-up. Prepare and follow-up on a list of CCBHC clients who need preventive or metabolic screening, appointment reminders; work with CCNS Nurses.
  • Participate with interdisciplinary team in tracking clients admitted to and discharged from the following facilities: emergency departments, hospital outpatient clinics, urgent care centers, residential crisis settings, and substance use disorder treatment programs offering a continuum of care to include outpatient with induction services and maintenance treatment for MAT, intensive outpatient or partial hospital programs, or centers of excellence or those with a specialty in treating OUD and when clinically indicated inpatient and residential treatment programs.
  • Assure timely and comprehensive transitional care from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing or treatment facility) to follow-up with post discharge interventions; transition/escort clients from inpatient settings back to the community and be an active leader in discharge planning with hospital teams- able to respond in person to hospitals upon learning a client is hospitalized.
  • Utilize regional health information organizations (RHIOs) and other data systems to track and share clients’ information and care needs across providers, monitor their outcomes, and initiate changes in care as necessary to provide prompt notification of an individual’s admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting and address immediate needs in order to maximize optimum care and timely treatments, services and referrals.
  • Able to utilize technology conferencing tools including audio, video and /or web deployed solutions and accountable for hand-held devices (I Phone, Blackberry, I Pad, Tablets, Laptops, etc.).
  • Responsible for maintaining the security of all data files and employing approved methods of data encryption to prevent theft of personally identifiable information.
  • Demonstrate commitment to the vision of the CCBHC and its strategic priorities to ensure their achievement.
  • Work schedule includes holiday coverage to accommodate the coverage needs of the program when required. 24 hours/seven days a week availability to provide information and emergency consultation services and provide escorts  to clients from ED, hospital and other  settings to alternative level of care within community.
  • Report to Integrated Health & Wellness Administration and/or Agency Administration issues that may have a negative impact on the reputation of the Agency, client and/or staff welfare or any corporate compliance issue.
  • Cooperate with any and all investigations conducted by the Agency, funding sources and any other authorized agencies/entities.
  • Attend required in-service programs and trainings. 
  • Collaborate with program management in the identification of developing marketing strategies.
  • Request in a timely fashion scheduled vacation and time off request from the Clinical Director to ensure continuous coverage of program’s activities.
  • Perform other related duties as requested or assigned by agency management.
  • As this is an evolving program, additional responsibilities may be added and/or revised.
  • Participate in committees as directed. 


  • Bachelor’s degree in social work, psychology or a related health/human services field with two (2) years of direct work with the target population. OR Professional Degree/certification in healthcare field.


  • The position requires a combination of skills in the areas of crisis intervention, time management, psychosocial rehabilitation skills
  • Ability in linking clients to a broad range of services essential to successfully living in a community setting (e.g., medical, psychiatric, social, educational, legal, housing and financial services).  Must have excellent communication skills.
  • Cross-cultural competency, outreach, interviewing, listening, advocating, linking, negotiating, engagement, monitoring and clinical assessment skills are essential.
  • Excellent computer skills are necessary.
  • Knowledge of the community medical resources and their financial requirements.
  • Good oral and written communication skills.
  • Fluency in second language preferred.


  • Ability to work flexible hours and days – including weekends/evenings/holidays according to needs of a 24/7 program.
  • Regularly required to talk, hear, walk, stand & sit.
  • Able to lift up to 10 pounds.
  • Able to climb stairs and make home visits.
  • Able to stretch and bend to retrieve files.
  • Able to operate a computer keyboard, mouse, & office equipment.
  • Able to read printed materials and computer screens.
  • Able to write.
  • Able to sit and work on the computer for long periods of time.
  • Able to travel to multiple locations as needed.

Other details

  • Pay Type Hourly
  • Required Education Bachelor’s Degree
Location on Google Maps
  • 1623 Flatbush Ave, Brooklyn, NY 11210, USA