Care Management is a team-based, patient-centered approach to health care, whereby all caregivers communicate and interface to address patient needs are addressed in a coordinated, comprehensive manner.
The "Care Manager – I" serves children with a “medium” or “low” acuity level, overseeing and providing access to all health services, seeking to maintain patient health and stability and prevent hospitalizations.
The Care Manager I is ultimately responsible for the overall provision and coordination of services to assigned caseload. He/she guides program enrollees and their caretakers (legal guardians) through the health care system by assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes.
MAJOR DUTIES/ RESPONSIBILITIES:
- Obtains required Care Management enrollment consents from the individual enrollee or legal guardian.
- Completes initial and ongoing Child and Adolescent Needs and Strengths (“CANS”) assessments to determine the enrollee’s most appropriate level of care management.
- Creates and implements Individualized Plan of Care for each enrollee on caseload. Through the Individual Plan of Care, the Care Manager:
- Coordinates provision of services to patients.
- Supports adherence to treatment recommendations.
- Monitors and evaluates patient needs, including prevention, wellness, medical, mental health, care transitions, and social and community services where appropriate.
- Meets client contact requirements (keeping in mind that caseloads may be “blended”):
- Care Manager - I will have face-to-face visits on a consistent schedule.
- Meets Care Management documentation requirements in a timely and accurate manner by effectively utilizing the Medicaid Analytics Performance Portal (“MAPP”) and Electronic Health Records (“EHRs”) as needed.
- Advocates for enrollees – both within the agency and with external service providers.
- Promotes wellness and prevention by linking enrollees with resources and services based on individual needs and preferences.
- Educates the enrollee and caregiver on care of chronic conditions and preventive interventions such as immunizations and screening.
- Helps clients to obtain and maintain public benefits necessary to gain health care services, including Medicaid and cash assistance eligibility, Social Security, SNAP, housing, legal services, employment and training supports, and others.
- Effectively communicates and shares information with enrollees and their families and other caregivers with appropriate consideration for language, literacy and cultural preferences.
- Conducts care planning meetings/conferences and serves as an interdisciplinary team member to effectively provide/coordinate comprehensive and holistic care.
- Identifies available community-based resources and actively manages appropriate referrals, access, engagement, follow-up and coordination of services.
- In the event of hospital admissions, actively engages in the discharge planning process, ensuring that the patient has all recommended post discharge services in place prior to discharge.
- Participates in ongoing staff development trainings to enhance skills needed to effectively meet the demands of the Care Manager – I position.
- Ensures that enrollee has periodic evaluations and follow up treatment for dental, vision and hearing care, following Medicaid EPSDT guidelines.
- All other duties, as needed by the agency.
SUPERVISES:
