Senior Reentry Case Manager

Intensive Reentry Case Manager provides comprehensive Clinical Services/Case Management services and referrals services to recently released participants from Cermak Jail/Illinois Department of Corrections. The Intensive Reentry Case Manager will collaborate with other internal and external providers to provide direct assistance to participants living in the community. The Intensive Reentry Case Manager will provide appropriate interventions, service plans and referrals to primary medical care, housing, mental health, and substance abuse to ensure continuity of medical care and medication compliance to lead to improved viral suppression.

The salary range for this role is $50,000 to $55,000 annually.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

Specific Responsibilities:

• Provide Corrections Case Management Services to individuals transitioning from Jail and Prison
• Assist clients with community transition providing essential services
• Assist and participate in ongoing one-on-one counseling and educational sessions on:
• HIV, Viral Life Cycle and Understanding ART
• Communicating with Provider, Adherence & Managing Side Effects
• Review understanding of basic lab tests: CD4 & Viral Load
• Stigma & Disclosure
• HIV and Substance Use
• HIV and Mental Health

Assessments & Service Plans

• Conduct face-to-face assessment and reassessments on an annual basis.
• Create care service plans that match the identified needs of the client.
• The care service plan should be developed with participants in-put, and it should be inclusive of all relevant core services (Primary Care, MH, SUD, and Supportive Service and referrals for Housing). Participant should be made aware of the importance of medication adherence and medical treatment compliance
• Care plan should assist client in maintaining a VL suppression rate of 95%.
• Collaborate with participants and Employment Specialist in developing and taking steps to achieve their personal and professional goals. This includes assistance with addressing such problems as personal and family adjustments, finances, employment, food, clothing, housing, (behavioral) health and physical and mental impairments. This could also include enrolling in benefits, opening bank accounts, obtaining phones and state IDs, finding transportation, and assisting participants in navigating through systems of health care and social service providers.
• Develop and maintain referral relationships for a range of support services.
• In collaboration with Employment Specialist, develop comprehensive services and resources to assist participants with their career and academic planning towards goals.
• Assigns acuity score along with the Participant, develops a service plan, and maintains a caseload, work with Participant and other providers to full the service plan. Service plans should include but not limited to addressing the despairing concerns post outside of Institutionalized and address concerns.
• With an authorized release of information, contact family members or other social supports of participants to discuss their reentry goals and how to support loved one upon release.
• Intensive Reentry Case Manager will create or refer Participant to support groups of behavioral health services.

Client Service

• Provide care services linkage and re-engagement support to clients recently released from jail and prison. Recently released is defined as within the last 24 months.
• Obtain an authorized release of Medical records and complete AIDS drug Assistance program (ADAP) forms.
• Conduct field visits as needed to RW and HOPWA clients who have disengaged from care.
• Conduct outreach services as needed.
• Provide Appointment reminders, arrange transportation.
• Contact participants when they No-Show for appointments
• Refer clients to appropriate services highlighted in the care plan.
• Refer clients to appropriate social supports to support positive reentry into society
• Screen for income supports for benefits and entitlements to advocate on behalf of client.
• Complete emergency financial assistance applications for eligible clients.
• Complete payment requests as needed for copays and other out of pocket costs.
• Document encounters using designated client database accurately and in a timely manner.
• Utilize the CCM assessment tool to incorporate specific needs, concerns, and issues as it relates to maintain recidivism issues lower and intervention strategies to keep them in mainstream society. Address the public health issues of corrections participants and maintain into medical care.
• Distribute and track MHealth (mobile health) phones for improved engagement in health, employment, and housing programs.
• Assist participants with accessing employment program.
• Advocate on participants behalf in qualified Expungement and assist Participant when participants who are eligible in the process
• Develop and maintains professional relationships with social service, health, and governmental agencies.
• Participate in continuous quality improvement efforts.
• Participate in regular supervision meetings, team meetings, in house training sessions (12) and conferences as needed.
• Follows assigned correctional participants transferred to other clinics until the case is closed, reassessed, and transferred.

Reporting

• Enter data in PROVIDE Enterprise Data System (PROVIDE) weekly monthly and use spreadsheets to track participants. Complete monthly report, quarterly and yearly reports to include participant trends and outcomes. Assures accuracy of data by providing supporting documents.
• Document medical release forms and ADAP and upload in PROVIDE
• Prepare and present internally/externally data collection/outcomes including demographics and backgrounds
• Submit monthly reports with demographics capturing metrics to AFC Supervisor
• Participant's record must reflect all face-to-face encounters and collateral contacts. All progress notes should be current, all medical assessments should be entered into PROVIDE and all Participant change of information and re-assessments should be entered into PROVIDE.
• Document all services, approvals, and denials to include completed outcomes and goals. Documentation should reflect acuity level during the reassessment and final case closure when levels are six and under.

Partner Relations

• Maintain an awareness of and cultivate relationships with local providers of services including food, housing, mental health and substance abuse treatment, and health.
• Provides referrals as needed to community agencies regarding specific needs and assist with accessing the needs. Maintain HIPPA/Consent for release of information when contacting agencies as it relates to patient confidentially by attaining Participant consent on each referral.
• Be familiar with state and local government agencies and their systems and processes for providing state identification, driver's licenses, SNAP and Medicaid enrollment, birth certificates, etc.
• Track resource and referral placements in a data collection system.
• Comply with all IDOC requirements, policies, rules, and regulations during performance of services for the Program and at all times while in IDOC facilities
• Attends AIDS Foundation of Chicago Corrections Case Management meeting, Community Reentry and Statewide Reentry meetings. Actively participate in monthly AFC meetings (10 per year), capacity building and training meetings and Community Reentry as requested.
• Attends trainings and seminars to keep abreast of current information and services. Must comply with all mandated trainings as it relates to your funding. A minimum of 12 training per year.

Other

• Assist with agency-wide activities as directed, including Annual Meeting, AIDS Run & Walk, and others.
• Protect organization's value and manage risk by keeping information confidential.
• Perform other duties as assigned.

The list of essential functions, as outlined herein, is intended to be representative of the tasks performed within this classification. It is not necessarily descriptive of any one position in this class. The omission of an essential function does not preclude management from assignment of duties not listed herein if such functions are a logical assignment to the position.

SUPERVISORY RESPONSIBILITIES
None
EXPERIENCE AND EDUCATION
Minimum Qualifications

• 5 to 6 years of experience with ability to pass background check to gain justice system clearance

Preferred Qualifications

• Associate degree in any human services field with at least 4 years of case management experience OR
• Bachelor's degree in any non-human services field with at least 2 years of case management experience
• Bi-lingual (Spanish speaking, reading, writing)
• Reliable transportation
  

• KNOWLEDGE, SKILLS, AND ABILITIES
• Exceptional time management skills
• Strong attention to detail
• Ability to present to large groups, and a comfort level with presentations generally
• Strong customer service orientation
  
• Ability to work independently and make decisions within span of control
• Dependable and reliable
• Knowledge of HIPAA and ability to comply with HIPAA regulations
• Ability to recognize and solve problems positively and sustainably

REQUIRED CERTIFICATES, LICENSES, REGISTRATIONS
None
WORK ENVIRONMENT AND PHYSICAL DEMANDS
Dependable transportation to conduct field visits. A driver's license, and car insurance may be required. Physical ability to operate a vehicle may be required. The field environment may contain ADA noncompliant spaces. The work environment is representative of that found in a general office environment. Tasks involve the ability to exert light physical effort in sedentary to light work, but which may involve some lifting, carrying, pushing and/or pulling of objects and materials of moderate weight (up to 10 pounds.) Tasks may involve extended periods of time at a keyboard or workstation and on the telephone.