Care Manager | Older Adult Services

Job Description

Job Description

SUMMARY

The Care Manager, Older Adult Services provides comprehensive care management, resource coordination, and program support to vulnerable older adults throughout Greater Philadelphia. Working as part of an interdisciplinary team, the Care Manager helps clients access community resources, benefits, healthcare, and supportive services that promote safety, stability, independence, and aging in place. The role uses a person-centered, trauma-informed approach and collaborates with clients, caregivers, healthcare providers, community partners, and internal departments to address each client's needs.

Services are delivered through a hybrid model that may include in-home visits, office-based services, community outreach, telephonic or virtual support, and remote work, based on client and program needs.

RESPONSIBILITIES

• Conduct comprehensive client assessments to identify cognitive, medical, functional, behavioral health, social support, safety, and environmental needs.

• Develop, implement, maintain, and update individualized care plans in collaboration with clients, caregivers, and the interdisciplinary care team.

• Maintain timely, accurate, and complete documentation of client interactions, assessments, care plans, progress notes, referrals, and billable services within the electronic health record.

• Perform caregiver assessments, provide education and support, and connect clients and families with appropriate community resources and services.

• Provide ongoing care management services in accordance with applicable program, payer, CMS, HIPAA, Medicare documentation, and organizational requirements.

• Advocate for clients by helping them navigate healthcare, behavioral health, benefits, housing, transportation, food access, and other community-based systems of support.

• Conduct routine client outreach to monitor health status, medication adherence, treatment follow-through, service needs, and progress toward care plan goals.

• Identify barriers to care and develop practical interventions to improve engagement, self-management, safety, and client outcomes.

• Facilitate communication among clients, caregivers, healthcare providers, and other members of the care team to support continuity of care.

• Track and document care management activities and time in accordance with applicable billing, reimbursement, and reporting requirements.

• Monitor quality measures and contribute to initiatives that improve client outcomes, satisfaction, compliance, and program performance.

• Participate in case conferences, trainings, supervision, department meetings, and other staff meetings as assigned.

• Perform other duties as assigned by the supervisor.

COMPETENCIES

• Knowledge of public benefits, entitlement programs, healthcare navigation, and community resources for older adults.

• Ability to apply applicable CMS, Medicare, HIPAA, documentation, billing, and compliance standards in service delivery.