ORGANIZATIONAL RELATIONSHIPS
Position Title: AOT Case Manager
Position Number: Date: 9/1/26
Employee:
Work Unit: Multiple County: Dougherty, Terrell, Lee
Immediate Supervisor's Title:
List positions supervised through immediate contact:
Number: Title:
- QUALIFICATIONS (including physical requirements)
Bachelor's degree in social work, psychology, sociology, human services, criminal justice, behavioral health, or a related field preferred. Equivalent education and relevant behavioral health case management experience may be considered in accordance with Aspire BHDD and applicable program requirements.
Experience providing case management, care coordination, community-based behavioral health services, or services to adults with serious mental illness (SMI) strongly preferred.
Must demonstrate knowledge of serious mental illness, co-occurring substance use disorders, community behavioral health systems, recovery-oriented services, social determinants of health, community resources, crisis services, and barriers that may interfere with treatment engagement.
Must possess strong engagement, communication, organizational, documentation, problem-solving, and relationship-building skills and demonstrate the ability to coordinate services across multiple systems.
Must be able to provide services in community settings and travel to participant homes, treatment facilities, hospitals, community agencies, court-related meetings, and other locations as required.
- EQUIPMENT THAT REQUIRES SAFE AND EFFECTIVE USE:
NONE
- BLOODBORNE PATHOGEN CATEGORY (check one)
____ Employee routinely performs tasks that involve exposure to blood or other potentially infectious material as part of their assigned duties (Category I).
____ Employee performs assigned tasks which does not involve exposure to blood or other potentially infectious material, BUT employment may require performing unplanned category I tasks (Category II).
__x__ Employee performs assigned tasks which involve no exposure to blood or other potentially infectious material AND performance of category I tasks are not a condition of employment (Category III).
- MANDATORY TRAINING CATEGORY (Check One)
__x__ Administrative __x__ Direct Care ____ Medical
- PERFORMANCE IMPROVEMENT
Aspire Behavioral Health and Developmental Disability's goal is to continually improve the delivery of service by improvement of individual outcomes and satisfaction. All employees have a role in performance improvement and are expected to interact collaboratively with co-workers and other contacts to provide consistent, high-quality, individually focused services.
G. SPECIAL NEEDS OF POPULATION SERVED
(Age Related, Cultural and Linguistic Competence)
The AOT Case Manager must demonstrate knowledge of and sensitivity to the complex needs of adults with serious mental illness who meet applicable criteria for Assisted Outpatient Treatment through the civil court system.
Individuals served may experience serious mental illness, co-occurring substance use disorders, histories of trauma, homelessness or housing instability, repeated psychiatric hospitalization or crisis utilization, difficulty maintaining consistent treatment engagement, limited natural supports, transportation barriers, financial instability, medical needs, and other social determinants that interfere with successful community living.
The Case Manager must provide services in a manner that is person-centered, recovery-oriented, trauma-informed, culturally responsive, strengths-based, and respectful of participant dignity, rights, preferences, and individualized needs.
Staff should be able to:
DESCRIPTION OF DUTIES AND RESPONSIBILITIES
a. Provide intensive, person-centered case management and care coordination services to individuals enrolled in Aspire BHDD's Assisted Outpatient Treatment Program.
b. Work collaboratively with participants, clinicians, peer specialists, medical providers, the Court Coordinator, AOT Project Director, and other members of the multidisciplinary AOT team to support implementation of individualized treatment and recovery plans.
c. Complete or assist with comprehensive assessment of participant strengths, needs, barriers, resources, natural supports, and social determinants affecting treatment engagement and community stability.
d. Develop, implement, monitor, and update individualized case management goals and interventions in collaboration with the participant and multidisciplinary treatment team.
e. Assist participants with accessing and maintaining behavioral health treatment, psychiatric services, medication management, substance use treatment, primary and specialty medical care, peer support, and other clinically appropriate services.
f. Coordinate services addressing housing, transportation, food security, financial resources, public benefits, employment, education, identification documents, insurance, legal resources, and other needs affecting participant stability.
g. Provide assertive outreach and engagement to participants who experience difficulty maintaining consistent involvement in treatment and community-based services.
h. Provide services in community settings whenever appropriate, including participant homes, shelters, hospitals, treatment facilities, community organizations, and other locations necessary to reduce barriers to care.
i. Identify barriers contributing to treatment disengagement, psychiatric instability, hospitalization, homelessness, crisis utilization, or other adverse outcomes and work collaboratively with the participant and AOT team to develop strategies to address those barriers.
j. Assist participants in developing practical skills necessary for successful community living, including appointment management, transportation planning, medication routines, communication with providers, accessing community resources, budgeting, and development of natural support systems.
k. Coordinate transitions between hospitals, crisis stabilization services, residential programs, outpatient providers, and other levels of care to promote continuity of treatment and reduce gaps in services.
l. Maintain regular contact with participants based upon individualized need and program expectations and promptly communicate significant changes in participant functioning, engagement, housing, safety, or treatment status to appropriate members of the AOT team.
m. Participate in multidisciplinary case staffing and communicate participant strengths, needs, barriers, progress, and service coordination needs to the AOT team.
n. Work collaboratively with the AOT Court Coordinator to support coordination of services associated with the participant's AOT civil court order while maintaining appropriate role boundaries between case management and court functions.
o. Assist participants in understanding and navigating the behavioral health and community service systems and reinforce information provided by appropriate program and court personnel regarding the AOT process.
p. Encourage participant voice, choice, self-advocacy, recovery goals, and active participation in treatment planning to the fullest extent possible.
q. Engage family members, natural supports, and significant others when authorized by the participant and clinically appropriate to strengthen community support and treatment engagement.
r. Coordinate with hospitals, crisis providers, outpatient providers, housing programs, community organizations, benefits agencies, transportation providers, and other community partners to promote timely access to needed resources.
s. Identify emerging participant needs or barriers and communicate them promptly to the multidisciplinary team so that interventions can occur before problems escalate whenever possible.
t. Assist with crisis prevention and safety planning in collaboration with clinical staff and connect participants to appropriate crisis resources when increased behavioral health needs are identified.
u. Document participant contacts, case management activities, referrals, service coordination, progress, barriers, outcomes, and other required information accurately and within established timeframes.
v. Assist with collection and monitoring of required AOT program data and outcome measures related to participant engagement, service utilization, housing, hospitalization, crisis utilization, and other established program outcomes.
w. Participate in Continuous Quality Improvement activities and assist the AOT team in identifying service gaps, participant barriers, and opportunities to improve program effectiveness.
x. Participate in AOT Management Team activities when requested, multidisciplinary case staffing, program meetings, community partner meetings, required trainings, SAMHSA-related activities as applicable, and other program initiatives.
y. Maintain confidentiality, professional boundaries, ethical standards, and compliance with HIPAA, Aspire BHDD policies and procedures, SAMHSA requirements when applicable, applicable Georgia statutes, and other state and federal requirements.
z. Perform other duties as assigned.
H. ASSIGNED DUTIES
DESCRIPTION OF WORK DUTIES AND RESPONSIBILITIES:
(Type in or attach current description of duties. Employees are expected to perform their work in a competent and efficient manner. Include % of time.)
Duties Include:
The AOT Case Manager provides intensive community-based case management and care coordination to individuals participating in Aspire Behavioral Health and Developmental Disabilities' Assisted Outpatient Treatment Program.
The position works collaboratively with participants and the multidisciplinary AOT team to identify and address clinical, social, environmental, and practical barriers that may interfere with treatment engagement and successful community living.
Responsibilities include coordinating access to behavioral health treatment, psychiatric and medical services, substance use treatment, housing, benefits, transportation, employment, peer support, and other community resources; conducting assertive outreach; assisting with transitions between levels of care; monitoring participant needs and progress; and maintaining communication with the multidisciplinary AOT team.
The AOT Case Manager serves as an important connection between participants and the systems necessary to support recovery and community stability. Services should emphasize participant engagement, continuity of care, development of natural supports, increased independence, and reduction of barriers that contribute to psychiatric hospitalization, crisis utilization, homelessness, and treatment disengagement.
Employees are expected to perform all assigned duties in a competent, ethical, efficient, trauma-informed, culturally responsive, recovery-oriented, strengths-based, and person-centered manner while adhering to Aspire BHDD policies and procedures, SAMHSA requirements when applicable, applicable Georgia statutes, HIPAA, grant requirements, and other applicable regulations.