Case Manager

Ryan Mahoney

Ryan Mahoney

Director of Product, FirstWho

“Case managers get hit from every side. They take in heavy emotional stuff all day without letting it wreck them, then turn around and make real things happen from that mess. You need someone who actually cares when a family's about to lose their housing, but can also draw the line so fifty other people don't get dropped. The hard part isn't being nice; it's being nice when everything's on fire. Can they really hear someone in crisis, then jump on the phone with a stubborn housing office, then write it all down clearly before the system garbles their notes? Working alone here isn't some bonus, it's the job. You're looking for someone who does solid work when nobody's checking, because that's most of their day.”

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Competency Questions

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Clinical Practice & Care Coordination

Delivering autonomous direct client services through comprehensive biopsychosocial assessment, crisis stabilization, and systematic care coordination across medical, social, and legal systems. Emphasis on independent clinical judgment and barrier navigation.

Care Coordination & Referral Management

Coordinates complex care transitions across multiple systems (health, housing, justice); negotiates referral priorities and timelines; resolves scheduling and transportation barriers; ensures clinical information transfer via CCDs or care summaries.

Interview round: Hiring Manager: Complex Case Assessment & Care Planning

Give me an example of a time you had to coordinate services across multiple agencies with conflicting requirements or timelines.

Positive indicators

  • Names specific coordination challenges overcome
  • Describes communication rhythm with partners
  • Mentions verifying service actually delivered

Negative indicators

  • Blames other agencies for breakdowns
  • No example of multi-party coordination
  • Left client to manage conflicts alone

Attitude Questions

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Active Listening

The disciplined practice of fully concentrating on, understanding, responding to, and remembering what another person communicates—encompassing verbal content, emotional tone, nonverbal cues, and unspoken implications—while suspending judgment, minimizing internal formulation of responses during the other's speech, and verifying comprehension through paraphrasing and clarifying questions rather than assumption.

Interview round: Hiring Manager: Complex Case Assessment & Care Planning

During a rushed phone call, a client mentions in passing that they're 'handling it like last time.' You don't know what 'last time' refers to and the call needs to end soon. How do you respond?

Positive indicators

  • Proposes specific clarifying question or callback plan
  • Mentions checking case notes or consulting colleagues
  • Considers whether 'handling it' indicates coping or crisis

Negative indicators

  • Lets reference pass without follow-up
  • Assumes meaning based on context
  • Relies solely on documentation without client verification

Progression Framework

This table shows how competencies evolve across experience levels. Each cell shows competency at that level.

Clinical Practice & Care Coordination

4 competencies

CompetencyJuniorMidSeniorPrincipal
Care Coordination & Referral Management

Executes warm handoffs and referral appointments; maintains referral tracking logs; communicates basic client information to external providers using release of information forms; follows up on appointment confirmations.

Coordinates complex care transitions across multiple systems (health, housing, justice); negotiates referral priorities and timelines; resolves scheduling and transportation barriers; ensures clinical information transfer via CCDs or care summaries.

Manages high-risk care transitions (hospital discharge, incarceration release); develops referral protocols and pathways; builds sustainable provider network relationships; troubleshoots systemic breakdowns in coordination.

Designs integrated care systems and accountable care models; establishes Memoranda of Understanding (MOUs) and data sharing agreements with health systems; evaluates coordination model effectiveness via network analysis.

Care Planning & Intervention

Implements standardized care plans and protocols under supervision; documents client progress toward goals; identifies routine barriers to goal attainment and escalates complex issues.

Develops individualized care plans with SMART goals; adapts evidence-based interventions based on client response and readiness; conducts crisis intervention and stabilization protocols independently.

Manages complex caseloads with multiple comorbidities and social determinants; designs specialized intervention protocols; provides clinical supervision; evaluates intervention fidelity and outcomes.

Creates evidence-based practice models and clinical guidelines; establishes outcome measurement frameworks; leads workforce development in intervention strategies; researches dissemination and implementation science.

Client Assessment & Intake

Conducts structured intake interviews using standardized screening tools and decision trees; documents presenting problems, immediate needs, and eligibility factors under direct supervision; recognizes urgent safety concerns for escalation.

Performs comprehensive biopsychosocial assessments independently across multiple domains (medical, psychiatric, social, vocational); identifies risk/protective factors; establishes diagnostic impressions; develops preliminary service plans.

Conducts complex diagnostic assessments for high-risk, co-occurring, or culturally complex populations; validates and calibrates assessment instruments; consults on difficult differential diagnoses; trains junior staff in assessment methodology.

Designs assessment frameworks, validation studies, and predictive risk models; establishes cross-agency assessment standards and interoperability protocols; leads research on assessment fidelity and outcome correlation.

Systems Advocacy & Resource Negotiation

Identifies potential client rights violations and barriers; maintains current resource directories; escalates advocacy needs to supervisors; documents advocacy activities.

Negotiates directly with landlords, utility companies, and administrative agencies; represents clients in fair hearings or eviction proceedings; coordinates with legal aid societies; resolves benefits denials.

Leads systemic advocacy campaigns targeting institutional policies; develops policy change proposals; chairs interdisciplinary advocacy coalitions; manages complex multi-party negotiations.

Designs advocacy strategies and campaign architectures; influences policy at legislative and regulatory levels; establishes institutional partnerships and strategic litigation support; leads field-building for client rights.

Data, Technology & Quality Systems

4 competencies

CompetencyJuniorMidSeniorPrincipal
Compliance & Quality Assurance

Follows compliance checklists and standard operating procedures; maintains current professional licensure and certifications; reports safety concerns through incident management systems.

Conducts quality assurance audits of case files and service delivery; implements risk assessments for client safety; ensures documentation meets accreditation standards (COA, CARF).

Manages accreditation preparation and site visits; develops compliance protocols and corrective action plans; investigates serious incidents; leads quality improvement teams using PDSA cycles.

Establishes organizational compliance and risk management frameworks; interfaces with regulatory bodies and auditors; sets enterprise quality standards; manages organizational liability and ethics.

Data Analysis & Outcome Evaluation

Collects and cleans data for analysis; runs standard reports from dashboards; documents data sources and limitations; maintains data dictionaries.

Performs descriptive statistical analysis; creates visualizations and dashboards; interprets trends in readmissions or service gaps; recommends specific service modifications based on findings.

Conducts complex statistical analysis (regression, survival analysis); develops evaluation frameworks and logic models; performs root cause analysis; leads outcome measurement strategy.

Designs research studies and quasi-experimental evaluations; establishes organizational analytics infrastructure; publishes findings in peer-reviewed venues; drives sector-wide learning and standards.

Digital Tools & Systems Navigation

Navigates basic case management software interfaces; inputs and retrieves data; troubleshoots common technical issues with IT support; maintains digital literacy for core platforms.

Optimizes workflow automation within systems; manages benefits enrollment portals (Medicaid, SNAP, SSI); trains clients on self-service portals and digital literacy; generates custom reports.

Configures system settings and user permissions; leads integration of new digital tools; evaluates accessibility and UX; drives digital transformation initiatives in service delivery.

Evaluates and procures enterprise case management systems; designs digital service delivery architectures; establishes technology infrastructure standards; ensures digital equity in access.

Information Management & Documentation

Enters client demographic and service data into EHR systems with high accuracy; maintains daily progress notes using structured templates; follows checklists for documentation completeness.

Manages complex documentation requirements including treatment plans and progress reviews; ensures HIPAA compliance in all disclosures; generates routine reports for supervisors; audits files for quality.

Oversees data quality assurance protocols; designs documentation workflows and templates; trains staff on regulatory compliance; manages complex inter-agency data sharing agreements.

Architects enterprise information systems and documentation standards; establishes regulatory compliance frameworks across programs; ensures audit readiness and legal defensibility of records.

Strategy, Advocacy & Organizational Development

4 competencies

CompetencyJuniorMidSeniorPrincipal
Community Engagement & Group Facilitation

Co-facilitates psychoeducational and support groups under supervision; assists with community outreach and event logistics; documents participation and feedback.

Leads evidence-based group interventions (CBT, DBT, trauma support); builds coalition networks with CBOs; organizes stakeholder forums; facilitates participatory community planning.

Designs group intervention curricula and trains facilitators; leads coalition-building for systems change; manages community advisory boards; scales engagement strategies regionally.

Establishes community governance and participatory budgeting models; leads large-scale community organizing campaigns; influences public narrative and policy through grassroots mobilization.

Program Development & Strategic Partnerships

Participates in community meetings and partnership activities; assists with data collection for needs assessments; maintains partnership contact directories.

Cultivates strategic community partnerships; conducts comprehensive community needs assessments; designs pilot programs and service innovations; mentors junior staff in partnership engagement.

Leads complex program design initiatives; manages multi-stakeholder collaborations; scales successful interventions across sites; drives continuous quality improvement using data.

Establishes regional and national strategic alliances; directs organizational strategy and new service line development; influences public policy and funding streams; builds sustainable impact ecosystems.

Resource Development & Grant Management

Assists with grant documentation and reporting; maintains donor and funder records; supports fundraising events and campaigns; tracks deliverable deadlines.

Writes competitive grant proposals for federal, state, and foundation funding; manages grant reporting requirements; cultivates donor relationships; ensures compliance with funding restrictions.

Leads diversified fundraising strategies; manages complex multi-year grants and contracts; develops earned income and social enterprise models; oversees institutional advancement.

Directs organizational development and revenue strategy; establishes endowment and planned giving programs; manages major donor portfolios and foundation relations; ensures long-term financial sustainability.

Workforce Development & Knowledge Management

Participates in professional development and training; documents lessons learned from cases; shares resources and best practices with peers; maintains personal learning plans.

Trains new staff and develops onboarding materials; implements competency-based supervision protocols; maintains knowledge repositories and resource libraries; facilitates team learning.

Designs competency frameworks and certification programs; leads clinical supervision and reflective practice groups; manages training departments; implements change management initiatives.

Establishes organizational learning strategy and culture; develops workforce pipelines and career ladders; architects enterprise knowledge management systems; leads organizational development and transformation.