Care Manager

Requirements-

Comprehensive Care Management
Complete a Comprehensive Assessment for each individual that identifies medical, mental health, chemical dependency, developmental disability, and social service need
Develop a Life Plan with the individual; include family, collaterals, and service providers in fulfillment of the Life Plan; parties should agree with the goals, interventions, and timeframes
Caseload size up to a weight of 20, generally 35-40 members, but may vary
Conduct face-to-face visits as required (Monthly, Quarterly, or Bi-Annually dependent on regulatory requirement and individual needs of each individual)

#2. Care Coordination and Health Promotion
Engage the individual in the adherence to treatment recommendations, monitor and evaluate individual’s needs coordinate all aspects of the individual’s care; develop relationship between the care planning team
Review and update the Life Plan with the care planning team; initiate changes in care
Ensure timely access to appointments for individuals to medical/behavioral health care services; link individuals with resources
Collaboration with both internal and external interdisciplinary teams.
Instituting recommendations from internal clinical teams
Involvement in post-hospital/rehabilitation discharge

#3. Comprehensive Transitional Care
Assist the individual to transition between levels of care, or after critical events, such as: hospital, school, rehabilitation facility, etc., follow up in a timely manner post discharge, support individual during crisis events
Use Health Information Technology to facilitate collaboration among all providers

#4. Individual and Family Support
Communicate and share information with individuals and their family/representative, ensure that the Life Plan reflects the individual’s and their family/representative’s preferences
Utilize peer supports, support groups to increase family/representative’s awareness
Provide monthly contact and engagement with all members/families
Follow up to strive for complete member satisfaction with TCC and external services

#5. Referral to community and social support services
Identify available resources and actively manage referrals, engagement, and follow-up
Ensure that the Life Plan includes community-based and other social support services that respond to the individual’s needs and preferences and contribute to achieve the individual’s goals
#6. Use of HIT link services
Meet the HIT standards in the delivery of core services and the Life Plan, as described in the manual
Maintain written documentation of service delivery and individuals’ information on the Electronic Health Record
System while practicing all HIPAA and Privacy regulations
Additional Responsibilities:
Monitoring/Assisting individuals with maintaining benefits (Food Stamps, Medicaid, and SSI)
Support individuals with P&P related to schooling, and any relevant issues
Report any incident of abuse, neglect, or maltreatment immediately
Other duties as assigned/requested

Specific Knowledge, Skills, and Abilities:
Excellent interpersonal skills, including conflict-management and knowledge of de-escalation techniques
Advanced ability to effectively communicate in both verbal and written manner
Computer software skills, particularly skills with Microsoft Suite
Ability to organize, schedule, and utilize time well
Capability to analyze situations accurately, prioritize, and take effective action