Key Responsibilities and Required Skills for Intensive Case Manager

🎯 Role Definition

The Intensive Case Manager (ICM) is a front-line clinical professional who provides high-intensity, ongoing case management and care coordination for clients with complex medical, behavioral health, substance use, housing, or justice-system involvement. The ICM conducts comprehensive biopsychosocial and risk assessments, develops person-centered treatment and discharge plans, performs frequent field visits and outreach, engages clients in evidence-based interventions (e.g., motivational interviewing, trauma-informed care), coordinates services across clinical and community systems, documents progress in the EMR, and monitors outcomes to reduce hospital readmissions and stabilize clients in the community. This role requires autonomous decision-making, advanced clinical judgment, cultural humility, crisis intervention skills, and the ability to manage a demanding caseload while maintaining regulatory compliance (HIPAA, Medicaid/Medicare rules).

📈 Career Progression

Typical Career Path

Entry Point From:

Licensed Clinical Social Worker (LCSW) or LMSW transitioning from outpatient case management
Registered Nurse (RN) or Public Health Nurse with discharge planning experience
Behavioral Health Technician or Care Coordinator with experience in community outreach

Advancement To:

Senior Intensive Case Manager / Lead Case Manager
Clinical Supervisor or Team Lead (Case Management)
Program Manager for Community Services or Transitional Care
Care Coordination Director / Utilization Management Lead

Lateral Moves:

Discharge Planner / Transition Specialist
Community Outreach Coordinator / Housing Navigator
Utilization Review Nurse or Behavioral Health Care Coordinator

Core Responsibilities

Primary Functions

Conduct comprehensive, strengths-based biopsychosocial assessments and risk assessments for new and existing clients, documenting clinical formulation, safety concerns, social determinants of health, and barriers to care in the EMR.
Develop individualized, recovery-oriented care plans with measurable goals, timeframes, and responsibilities, coordinating treatment planning across psychiatry, primary care, housing, and social services to ensure continuity of care.
Provide high-frequency, community-based outreach and engagement including home visits, shelter visits, and field interventions to re-engage clients who are high risk for hospitalization, incarceration, or homelessness.
Deliver crisis intervention and safety planning during behavioral health emergencies, including de-escalation, coordination with mobile crisis teams, and facilitation of emergency services when necessary to ensure client and community safety.
Coordinate medication management and psychiatry follow-up by liaising with prescribers, monitoring adherence, identifying medication side effects, and arranging transportation or directly observed therapy when indicated.
Facilitate warm handoffs and transitions across levels of care (inpatient, residential, outpatient, primary care) to reduce readmissions and ensure clients have actionable discharge plans and follow-up appointments.
Provide advocacy and benefits coordination, assisting clients with enrollment and appeals for Medicaid, Medicare, SNAP, SSI/SSDI, housing vouchers, and other entitlement programs to remove systemic barriers to care.
Monitor caseloads proactively by scheduling regular check-ins, tracking clinical progress against SMART goals, and adjusting service intensity based on dynamic risk and acuity.
Lead multidisciplinary case conferences and care coordination meetings with psychiatrists, PCPs, substance use counselors, housing agencies, probation officers, and family members to align interventions and prevent service fragmentation.
Deliver evidence-based interventions, such as motivational interviewing, brief CBT strategies, relapse prevention planning, and trauma-informed approaches to support behavior change and recovery.
Maintain timely, accurate, and compliant documentation in EMR/EHR systems, including progress notes, incident reports, treatment plans, consent forms, and outcomes metrics for audits and quality improvement.
Identify and address social determinants of health by linking clients to food assistance, housing resources, transportation, employment support, and community supports that directly impact treatment adherence and recovery.
Manage complex risk and safety issues by developing and implementing safety plans, coordinating with law enforcement and crisis services as needed, and following agency protocols for reporting and follow-up.
Track and report outcome metrics (e.g., reduced ED visits, improved housing stability, treatment retention) and participate in program quality improvement initiatives to demonstrate program impact and secure funding.
Provide education and skills training to clients and families on symptom management, relapse prevention, medication adherence, tenancy skills, and community navigation to increase client self-efficacy and independence.
Initiate and maintain collaborative relationships with community providers, shelters, housing authorities, courts, and peer-run organizations to expand the referral network and ensure timely access to services.
Conduct outreach to hard-to-reach populations (e.g., individuals experiencing chronic homelessness, recently released from incarceration, or with co-occurring disorders) using engagement strategies tailored to cultural and linguistic needs.
Perform frequent follow-up with high-risk clients by phone, text, telehealth, or in-person visits to monitor safety, adherence, and crisis signs, escalating to higher levels of care when clinically indicated.
Supervise and mentor junior case managers, peer specialists, or interns as assigned, providing clinical guidance, case consultation, and training on agency protocols and evidence-based practices.
Ensure compliance with all regulatory, ethical, and billing requirements (HIPAA, state mental health regulations, Medicaid documentation standards) and support accurate billing for case management services.
Participate in community outreach events, multi-agency planning tables, and stakeholder meetings to represent the program, identify system-level gaps, and support population-level interventions.

Secondary Functions

Support data collection and program evaluation by entering standardized assessment data, client outcomes, and service utilization metrics into reporting systems.
Contribute to program development and refinement by providing frontline feedback on service gaps, client needs, and recommended protocol changes.
Assist with grant-funded program deliverables by documenting outcomes, participating in fidelity reviews, and preparing ad-hoc reports for funders.
Engage in continuous professional development, attending trainings on trauma-informed care, cultural competence, suicide prevention, and best practices in case management.
Help develop and distribute client-facing resources, referral directories, and educational materials to improve access and client self-management.
Support onboarding of new staff by participating in orientation, modeling field techniques, and training on documentation and safety procedures.
Coordinate occasional administrative tasks such as scheduling, inventory of outreach supplies, and maintenance of community resource lists.
Participate in agency emergency preparedness drills and contribute to the organization’s continuity-of-care planning.

Required Skills & Competencies

Hard Skills (Technical)

Proficient documentation in EMR/EHR systems (e.g., Epic, Cerner, Netsmart, Credible) with experience meeting Medicaid/Medicare documentation and billing requirements.
Advanced clinical assessment skills including biopsychosocial assessment, suicide and violence risk assessment, and crisis triage.
Expertise in care coordination across behavioral health, primary care, housing, and social services, including warm handoffs and discharge planning.
Competence in evidence-based interventions: motivational interviewing (MI), trauma-informed care, brief CBT techniques, and relapse prevention strategies.
Knowledge of community resources and systems (housing authorities, behavioral health providers, social services, probation/parole).
Familiarity with public benefits systems (Medicaid, Medicare, SNAP, SSI/SSDI) and experience supporting client applications and appeals.
Ability to create measurable treatment plans and use outcome measures (e.g., PHQ-9, GAD-7) to monitor progress.
Proficiency with mobile outreach logistics: scheduling field visits, ensuring safety protocols, and using geo-location or routing tools when applicable.
Strong documentation and reporting skills for quality improvement, audits, and grant reporting.
Working knowledge of confidentiality and legal/regulatory frameworks (HIPAA, mandated reporting, informed consent).

Soft Skills

Empathetic, nonjudgmental engagement style with demonstrated cultural humility and trauma-informed communication.
Exceptional verbal and written communication skills for client interactions, multidisciplinary collaboration, and professional documentation.
Strong clinical judgment and decision-making under pressure with the ability to prioritize high-acuity needs.
Excellent organizational and time-management skills to manage a high-intensity caseload and rapidly changing priorities.
Resilience and emotional intelligence to maintain professional boundaries while supporting clients in crisis.
Problem-solving orientation with creativity in identifying community-based solutions and alternative resources.
Assertive advocacy skills to negotiate services, housing placements, and entitlements on behalf of clients.
Collaborative team-player who can lead case conferences and effectively coordinate across disciplines.
Flexibility and adaptability to work varied hours, participate in on-call rotations, and perform field-based outreach.
Commitment to ethical practice, client confidentiality, and continuous professional learning.

Education & Experience

Educational Background

Minimum Education:

Bachelor’s degree in Social Work, Nursing, Psychology, Public Health, Human Services, or related field.

Preferred Education:

Master’s degree (MSW, MSN, MPH, MA psychology) or professional license (LCSW, LPC, LMFT, RN) preferred; certifications in case management (CCM, CCMC), Certified Peer Specialist, or equivalent are a plus.

Relevant Fields of Study:

Social Work
Nursing
Psychology
Public Health
Human Services

Experience Requirements

Typical Experience Range:

2–5 years of progressive case management or clinical experience working with high-acuity populations (serious mental illness, co-occurring substance use disorders, homelessness, or justice-involved clients).

Preferred:

3–5+ years of intensive/community-based case management experience, demonstrated success reducing hospitalizations/housing instability, plus experience with evidence-based practices (MI, trauma-informed care) and EMR documentation in Medicaid-funded programs.