Care Manager - Hybrid Remote

Job Description

Job Description

Job: Care Managers

$50k - $60k

Remote (NY once a quarter)

Full-time

Job Description:

The role of the Care Manager is to deliver the 6 core services in a person-centered manner in order to meet the needs of the individual, the OPWDD valued outcomes, the objectives of the People First Transformation, and the State requirements. The Care Manager provides referral and linkage to benefits and services, and in-person visits with members ranging from monthly to bi-annually dependent on the need of each member.

Required Education, Experience, and Licenses:

a) A Bachelor’s degree with two years of relevant experience, OR

b) A License as a Registered Nurse with two years or relevant experience, which can include any employment experience and

is not limited to case management/service coordination duties, OR

c) A Master’s degree with one year of relevant experience

d) MSC Service Coordinators prior to July 1, 2018 are “grandfathered” to facilitate continuity of care

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