EPICC Case Manager

JOB DESCRIPTION

JOB TITLE: EPICC Case Manager (High Utilizer Initiative)

REPORTS TO: EPICC Program Director

EMPLOYMENT STATUS: Full-Time; 10-month Contract ending Aug 31, 2027 (might have an opportunity for continued employment, dependent on funding and performance)

SALARY RANGE:  $55,000 - $75,000 USD per year

JOB SUMMARY: The Behavioral Health Network of Greater St. Louis (BHN) is seeking a contracted Case Manager to pilot a 10-month initiative to serve high need/high risk individuals with opioid addiction. This position will provide intensive, individualized case management and care coordination to individuals with three or more referrals to the EPICC (Engaging Patients in Care Coordination) program who experience ongoing challenges with treatment engagement, service access, and continuity of care. This position will focus on identifying and addressing barriers to treatment and recovery, facilitating connections to community-based services, and coordinating care among EPICC staff, peer recovery support specialists, treatment providers, hospitals, and other community partners. Through a person-centered, trauma-informed, and harm-reduction approach, the Case Manager will help participants navigate complex systems of care, increase engagement in substance use disorder treatment and recovery-support services, and improve overall stability while reducing the likelihood of repeated overdose-related emergency department visits and EPICC referrals. It is anticipated that the individual selected will work between 32-40 hours per week. Given it is a contractual role, this opportunity affords great opportunity for flexibility.

AREA OF FOCUS: The EPICC program is a collaborative opioid overdose response initiative that connects individuals encountered through emergency rooms (ER) and emergency medical services (EMS) with community-based substance use treatment and recovery services, with an emphasis on medication-assisted treatment (MAT). Through intensive outreach and engagement, EPICC Recovery Coaches, individuals with lived experience, help facilitate connections to treatment and recovery resources. The program aims to engage individuals during emergency room stabilization, increase access to substance use disorder treatment and MAT, provide Opioid Overdose Education and Naloxone Distribution (OEND), and reduce future overdoses and emergency department utilization.

This Case Manager will provide enhanced case management services to individuals who have been referred to EPICC three or more times and demonstrate ongoing challenges with treatment engagement, service access, or continuity of care. 

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Comprehensive Needs Assessment

• Review participant EPICC referral and engagement history to identify service needs and patterns of repeated referrals.
• Conduct individualized assessments to identify substance use, behavioral health, healthcare, housing, transportation, and social support needs.
• Identify existing service providers, immediate needs, and barriers to accessing care.
• Facilitate appropriate referrals based on identified needs.

Individualized Engagement and Service Planning

• Develop person-centered engagement and service plans that establish achievable short-term and long-term goals.
• Identify barriers contributing to repeated EPICC referrals and develop strategies to address them.
• Coordinate individualized engagement strategies with assigned Peer Support Specialists and other EPICC team members.
• Review and update service plans as participant needs and circumstances change.

Intensive Case Management and Care Coordination

• Facilitate connections to substance use disorder treatment, including medication-assisted treatment (MAT) when appropriate, as well as mental health and primary healthcare services.
• Assist participants with accessing housing, public benefits, transportation, food assistance, and other community-based resources.
• Coordinate with existing providers to promote continuity of care and minimize duplication of services.
• Support appointment scheduling, follow-through, and navigation of complex healthcare and social service systems.
• Facilitate warm handoffs to treatment providers, recovery organizations, and other supportive services.

Enhanced Follow-Up and Engagement

• Provide consistent, individualized outreach and follow-up to support participant engagement in treatment and recovery services.
• Reassess barriers when participants miss appointments or discontinue services and implement strategies to encourage reengagement.
• Coordinate with EPICC staff following additional program referrals or changes in participant needs.
• Document outreach attempts, successful contacts, and participant engagement outcomes.

Multidisciplinary Collaboration

• Participate in scheduled EPICC high-utilizer case reviews and case consultation meetings.
• Collaborate with assigned Peer Support Specialists, EPICC staff, hospitals, treatment providers, recovery organizations, and other community partners to coordinate care.
• Communicate service gaps and systemic barriers to EPICC leadership and recommend strategies to improve participant engagement and service access.

Documentation and Reporting

• Maintain timely and accurate documentation in the BHN-designated system, including assessments, service plans, participant contacts, referrals, and outcomes.
• Track participant engagement, progress toward service goals, barriers to care, and connections to treatment and recovery-support services.
• Submit monthly service activity and outcome reports in accordance with BHN requirements.
• Maintain participant confidentiality and comply with applicable privacy requirements, program procedures, and documentation standards.

QUALIFICATIONS, SKILLS, AND KNOWLEDGE REQUIREMENTS:

• Master's degree in social work, counseling, psychology, human services, or a related field preferred; equivalent relevant education and experience may be considered.
• Experience providing case management services to individuals with substance use disorders, opioid use disorders, or complex behavioral health needs.
• Knowledge of substance use disorder treatment options, including medication-assisted treatment (MAT), and community-based recovery-support services.
• Familiarity with local treatment providers, housing resources, transportation assistance, public benefits, and other community support services.
• Experience conducting outreach and engaging individuals who experience difficulty accessing or participating in traditional service models.
• Understanding of trauma-informed, person-centered, and harm-reduction approaches.
• Ability to develop individualized service plans, identify barriers to care, and implement practical strategies to improve participant engagement.
• Strong communication and interpersonal skills, with the ability to build rapport and establish effective working relationships with individuals experiencing complex life challenges.
• Strong organizational, time management, and documentation skills, with the ability to manage competing priorities and maintain accurate records.
• Ability to work independently while collaborating effectively with multidisciplinary teams and community partners.
• Ability to navigate complex healthcare, behavioral health, and social service systems and coordinate services across multiple providers.
• Professional judgment, appropriate boundaries, and a demonstrated commitment to participant confidentiality.
• Ability to recognize and appropriately communicate participant safety concerns.
• Willingness to participate in required program orientation, training, case consultation, and reporting activities.

WORK CONTEXT: 

Body Positioning 

• Must be able to remain in a stationary position at least 50% of the time.
• Must be able to operate a computer and other general office equipment such as a copy machine and printer.

Work Setting

• Hybrid. Office site is environmentally controlled.
• Must have a valid driver’s license (with no more than 2 points on the record) and current insurance.
• Required ability to drive to and from occasional meetings in the 7-County region represented by BHN.