CARE MANAGER (FULL-TIME)
The primary responsibilities of the Care Manager are to:
- Plan, coordinate, track, and close gaps in care.
- Monitor care to individuals to help them achieve the key goals of their behavioral health tailored plan. Lead all communication among care team members.
- Act as the primary point of contact for the member served.
- Complete a comprehensive assessment and develop a unified plan of care for the Tailored Plan recipients.
- Relay communication among providers of health services.
- Complete all required documentation
Essential Job Functions:
Complete Assessment/Planning
- Complete comprehensive assessment at enrollment, yearly, or at changes in condition.
- Develop Plans of Care derived from the completed assessment.
- Submit referral to the Integrated Health Consultant when a physical health or behavioral health need indicates medical and/or pharmaceutical complexity.
- Assist individuals/legally responsible persons in choosing service providers, ensuring objectivity in the process.
- Consistently evaluate appropriateness of services and ensure implementation of plan of care through information gathering and assessment at defined frequency of contact based on risk stratification.
- Utilize person-centered planning, motivational interviewing, and historical review of assessments to gather information and to identify supports needed for the individual.
- Actively collaborate with care team, consumers, and service providers to ensure development of a plan that accurately reflects the individual’s needs and desired life goals.
Support & Monitoring for Consumers
- Schedule initial contact with consumer to verify accuracy of demographic information. Update inaccurate information from the Global Eligibility file.
- Complete activities related to the plan of care.
- Schedule and facilitate the ISP meeting.
- Develop and update the ISP.
- Submit requests for services and purchase orders for products, supplies, and services covered under the Innovations Waiver.
- Coordinate with other team members to ensure smooth transition to appropriate level of care.
- Update other care team members of urgent or pertinent treatment updates.
- Recognize and report critical incidents to supervisor.
- Escalate complex cases and cases of concern to supervisor.
24:7 Call Crisis Response Coordination
- Identify and provide emergency crisis response as necessary, following agency policies related to crisis. Participation in agency on-call structure is required.
- Participate in post crisis team debriefing and provide feedback on ways to prevent future crises for the consumer.
Coordinate Care Transition
- Coordinate follow-up services for individuals with recent inpatient hospitalization or Emergency Department visit within 24 hours of discharge
- Coordinate after care needs for transitions in care such as release from incarceration, change in housing, or other life transitions.
Minimum Requirements:
Education: Bachelor’s degree in Health, Social Work, Human Services, Psychology, or related field required. Master’s degree in a human service field preferred.
Experience: Minimum of two (2) years, post bachelor’s degree accumulated experience with the population served, or one (1) year post-graduate degree accumulated experience with the population served.
License/Certification: Current CPR and First Aid certification required.
Knowledge: Comprehensive knowledge of community resources is required. Knowledge of specific aspects of service provision and population served that would be necessary to perform the technical functions of the position (including crisis management and on-call responsibilities). Knowledge of the principles of self-determination, freedom, and civil rights as applied to a traditional case management model of service delivery.
Or any equivalent combination of the above-listed requirements.
