Family Recovery & Environmental Case Manager

Valcore Health • Growing Rural Opportunities for Well-being (GROW)

Region/Program: Region6 /• NEST — integrated maternal, family, behavioral health, psychiatric, and substance-use care

Approved E.1 Position: Family Recovery & Environmental Case Manager (Social Worker)

Initiative Allocation: NEST

Grant Cost Class: Programmatic / non-administrative

Staffing Basis 1.0 FTE; one funded position per current E.1

Reports To: GROW Program Director or designee

Clinical Accountability: Indiana LCSW supervisor when social-work practice or LSW/LBSW supervision is required; designated clinical lead for safety escalation.

Position Status: Year One funded position, subject to final award, approved E.1, and hiring plan.

Position Purpose

Coordinate whole-family recovery, environmental and social-needs response, and closed-loop connections so high-risk families can engage with clinical care and remain connected through pregnancy, postpartum, recovery, and other vulnerable transitions.

Regional setting: Region 6, with primary field deployment in Jefferson, Jennings, and Switzerland counties and expansion within the approved regional service area; home-, community-, partner-site-, mobile-, and telehealth-enabled care for high-risk pregnant and postpartum people and their families.

Role in the Region-Specific GROW Model

· Work as part of NEST's single in-place model joining prenatal, postpartum, reproductive, behavioral-health, psychiatric, addiction, and family-support services.

· Use coordinated referral, documentation, escalation, and partner workflows with BLOOM, Well Care FFM, Life Choices, hospitals, OB/GYN, local health departments/WIC, DCS, and other approved coalition partners.

· Lead whole-family social/environmental stabilization and closed-loop resource work so clinical access gains are sustainable outside the encounter.

· Support NEST re-engagement, partner case conferences, and quarterly maternal-child-health workshops with de-identified/system-level learning where appropriate.

Shared outcome contribution: earlier prenatal connection, full-term and healthy-birth-weight outcomes, new access points, closed-loop referrals, and durable clinical/community integration. The role is accountable for its documented work and care-process contribution, not for claiming sole causation of population outcomes.

Essential Functions

· Complete role-appropriate social, environmental, family-safety, recovery, access, and resource assessments using approved tools; identify urgent needs and escalate clinical or safety concerns immediately.

· Develop and update person- and family-centered service plans with clear goals, responsible parties, due dates, consent, and follow-up steps.

· Connect participants to housing, food, transportation, benefits, legal, domestic-violence, child/family, recovery, treatment, and other community resources; verify whether connections were completed and barriers resolved.

· Provide intensive outreach and re-engagement for missed visits, transitions, hospital/ED discharge, treatment interruption, or changing family risk.

VALCORE HEALTHGROW REGION 6 | JOB DESCRIPTION

· Coordinate with clinical staff, DCS and other public agencies when legally and operationally appropriate, hospitals, local health departments/WIC, recovery organizations, and community partners using valid consent and minimum-necessary information.

· Support recovery-oriented planning, relapse-risk response, practical family stabilization, and environmental risk reduction without providing psychotherapy or independent clinical treatment unless separately licensed, privileged, and assigned.

· Maintain a current resource inventory, surface service gaps to the coalition, and help test referral and escalation workflows.

Measurement, Documentation & Grant Accountability

Maintain source records that permit Valcore and the regional coalition to aggregate, validate, stratify, explain, and report performance. Use official measure specifications and approved definitions; identify missing data, denominator limits, duplication risk, and attribution limits rather than estimating unsupported results.

Accountability Area: Family engagement and stability

Required Evidence / Contribution: Completed assessments/plans, goals, follow-up status, re-engagement, participant-reported barriers, and documented escalation.

Accountability Area: Closed-loop resources

Required Evidence / Contribution: Referrals initiated, accepted, completed, unresolved, declined, and time to closure by need type and geography.

Accountability Area: Access continuity

Required Evidence / Contribution: Appointment/navigation completion, missed-visit recovery, transition contacts, and service retention.

Accountability Area: Coalition learning

Required Evidence / Contribution: Resource gaps, workflow failures, workshop participation, and corrective actions supported by source notes.

· Follow the approved GROW grant agreement, current E.1 budget justification, regional work plan, logic model, outcome-measure appendix, Valcore policies, and written grant-change controls. Do not materially alter the funded purpose, FTE allocation, initiative assignment, or deliverable without authorized approval.

· Create timely, accurate, auditable source documentation for services, outreach, referrals, training, partner activity, time and effort, travel, deliverables, and role-relevant outcomes. Support CMS/State monitoring, quarterly and annual reporting, audits, corrective actions, and record-retention requirements.

· Protect information under HIPAA, 42 CFR Part 2 when substance-use-disorder records are involved, Indiana confidentiality law, and Valcore security policies. Use approved systems and the minimum information necessary; immediately report privacy, security, safety, fraud/waste/abuse, and compliance concerns.

· Maintain grant-cost integrity. Do not supplant unsupported existing salary costs, duplicate reimbursement, or charge unallowable activity. Keep grant-funded, billable, nonbillable, administrative, and other-program time and costs appropriately separated as directed.

Professional Scope, Supervision & Decision Boundaries:

· Does not diagnose, prescribe, independently provide psychotherapy, make custody/legal determinations, or perform nursing tasks unless separately licensed and formally assigned.

· Follows mandatory-reporting, imminent-risk, domestic-violence, abuse/neglect, and emergency-escalation law and policy; explains limits of confidentiality.

· Obtains valid consent before cross-agency coordination except where disclosure is required or permitted by law.

Required Qualifications:

· Bachelor's degree in social work or a closely related human-services field plus relevant case-management experience.

· If hired or represented as a social worker, active Indiana LBSW, LSW, or LCSW licensure appropriate to the duties. An LSW/LBSW must receive required practice supervision; LCSW is preferred for clinical-social-work functions.

· A nonlicensed candidate may be hired only under the title Case Manager, with duties limited to nonclinical navigation/case-management functions and no representation as a licensed social worker.

· Training or experience in recovery, maternal/family health, trauma-informed care, social drivers of health, crisis escalation, and community systems.

· Valid driver's license, reliable regional travel, and ability to work safely in home/community settings.

Preferred Qualifications:

· LCSW or LSW with qualifying supervision.

· Certified case-management, peer-recovery, CHW, or perinatal-support credential.

· Experience with Medicaid, child/family systems, rural resources, and closed-loop referral platforms.

Core Competencies:

· Trust-building and motivational engagement

· Complex case organization

· Boundary management

· Crisis recognition and escalation

· Closed-loop referral practice

· Accurate grant and case documentation

Compliance, Ethics & Participant Rights:

· Provide person-centered, trauma-informed, culturally responsive, accessible, and nondiscriminatory service. Use qualified language assistance and reasonable accommodations when needed, and follow informed-consent and patient-rights requirements.

· Complete required screening, credentialing, exclusion checks, training, competency validation, and annual refreshers. Cooperate with quality-improvement reviews and implement corrective action within assigned authority.

· Follow current applicable federal and Indiana requirements, including professional licensing and delegation rules, Indiana telehealth standards, MIH/EMS requirements when applicable, HIPAA, 42 CFR Part 2, emergency and mandatory-reporting duties, and organizational clinical governance.

· Immediately disclose and manage conflicts of interest. Do not accept impermissible inducements, falsify documentation, conceal errors, retaliate, or knowingly submit inaccurate program, financial, time, clinical, or performance information.

Work Environment, Travel & Schedule:

· Frequent regional travel and work in homes, community/partner sites, mobile settings, and telehealth; conditions and schedules may change with participant and deployment needs.

· May encounter rural connectivity limits, sensitive family circumstances, behavioral-health crises, pregnancy/postpartum emergencies, weather, and variable physical environments; follows field-safety and emergency protocols.

· Reasonable accommodation is available. Final physical and schedule requirements will reflect the actual credentialed duties and deployment model.

Role Flexibility & Change Control:

Controlled flexibility: This grant-funded role is designed to evolve as community needs, CMS/Indiana guidance, approved performance measures, payer requirements, technology, partner capacity, and implementation evidence change. The employee may be assigned related duties, locations, populations, workflows, or approved initiative activities that are reasonably consistent with the role's purpose, qualifications, professional scope, and approved GROW plan. Material changes to clinical scope, credential requirements, grant initiative, funded FTE, budget classification, or committed outcomes require documented leadership and grant-authority review before implementation.

Document Control:

Effective/review date: August 24, 2026; review at least annually and whenever the approved E.1, work plan, grant conditions, role scope, law, or operating model changes.

Controlling references: Region 6 approved E.1 budget justification; Region 6 work plan, logic model, and project narrative; GROW RFF and appendices; applicable CMS/HHS post-award terms; current federal and Indiana law and Valcore policy.

Document purpose: This description defines current essential functions and grant alignment. It does not create a contract, guarantee funding or employment duration, expand professional scope, or replace current law, privilege, supervision, or clinical policy.

Acknowledgment:

I acknowledge receipt of this job description and understand that duties

must be performed within applicable law, credential, competence, policy, supervision, and approved grant scope.

Employee signature                                Date

Supervisor signature                              Date

Steven’s Amendment 

This Rural Health Transformation Program is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $206,927,896.80 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.” 

 

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