Adult Care Transitions Specialist

4 weeks ago


Utica, New York, United States ICAN Inc Full time
Job Description

The Adult Care Transitions ICM is responsible for conducting and scheduling assessments, referrals, advocacy, and supports to ensure clients receive quality intensive services and maintain optimum healthcare needs without barriers.

Duties and Responsibilities:

  • Provide Intensive Case Management services to hard-to-serve individuals, including those pending discharge from hospital acute care, emergency department care, or other institutional settings.
  • Collaborate with the Oneida County Department of Social Services to conduct assessments, evaluate needs, and establish referrals for enrollees.
  • Provide a safety net to address the needs of individuals who are pending discharge, who have few or no natural supports, to help ensure their safety and successful connection to services and care in the community.
  • Plan for a safe and successful discharge for reintegration into the community upon referral.
  • Participate in regularly scheduled multidisciplinary case conferences addressing immediate or ongoing safety needs and assistance with accessing benefits, services, stable housing, and housing support services.
  • Develop a Safety Plan and Plan of Care based on preliminary information to identify linkages and services immediately required.
  • Monitor individuals on their caseload for up to 90 days to ensure satisfactory implementation of community-based services and adjust services as needed.
  • Ensure all initial linkages are established and maintained, and advocate for additional services and linkages as appropriate.
  • Collaborate with all service providers and establish a team communication plan.
  • Monitor goals on a continuing basis and ensure team communication.
  • Monitor and ensure that the care plan is relevant to Intensive Case Management standards.
  • Consult with family members and social supports to maintain support consistency.
  • Maintain current case documentation and information regarding clients within the required EHR system.
  • Work with the client on discharge to a program that fits their needs and is a benefit to their safety and well-being.

Education/Experience:

  • Bachelor's degree (B.A.) from an accredited four-year college or university, in Human Services, a mental health field, or a related field is preferred.
  • At least two years of experience in Human Services, primarily Mental Health and Substance Abuse.
  • Knowledge of Microsoft Office Suite, Google Suite, and AWARDS.
  • Valid NYS Driver's License is required.


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