CAP Case Manager

CAP Case Manager

The CAP Case Manager professional manages Community Alternative Program clients and provides medical social work assistance to agency home health patients. The role collaborates with the client, family, agency clinical staff, and other health care providers to facilitate client access to health and social services that enhance the client's well‑being and ability to adhere to prescribed medical treatment. The case manager provides case management services to an assigned CAP client caseload as directed by the Home Care and CAP Supervisor, and medical social work for home health patients as assigned, collaborating with the Clinical Programs Manager.

The position also facilitates access to requisite resources, identifies new resources, and provides services to adult clients in homes and clinical settings.

• Contributes to service excellence at the unit, division, and hospital level.
• Supports the House Rules of Excellence by incorporating the standards into daily work behaviors.
• Integrates continuous quality improvement process into day‑to‑day functions by accepting responsibility for the quality of individual job performance.
• Seeks opportunities to continuously improve the delivery of service provided to clients, patients, families, employees and physicians by making suggestions or recommendations through management, department meetings or other forums.
• Performs as a team member by generating ideas, respecting the opinions and contributions of the team and supporting the teams recommendations and suggestions.
• Demonstrates an acceptable level of work habits behavior.
• Adheres to work schedule and arrives to work on time.
• Adheres to allotted time frames for breaks or meals.
• Dresses appropriately for work area.
• Keeps personal phone calls/visits to a minimum.
• Avoids making false, malicious, abusive, or threatening statements to or about employees, management or the organization.
• Conducts non‑work related conversations at appropriate time and place.
• Maintains client and patient confidentiality.
• Follows safe working procedures.
• Provides social work case management services to an assigned client caseload.
• Completes initial client/family social work assessments of CAP other case management clients within one week of initial client encounter. Participates in the development of the clients Plan of Care and provides information on needs for equipment, supplies, other home care services to be included in plan of care.
• Performs home visits when indicated and at minimum frequency stated in policies and regulations.
• Collaborates with client and appropriate personnel to develop and maintain current case management plans which are consistent with clients current and potential problems, the medical care plan, client goals, and financial resources.
• Effectively communicates case management plans, upcoming Medicaid spend downs and other client‑related activities both verbally and in writing to appropriate personnel and agencies.
• Perform follow‑up assessments (at least monthly or more often when appropriate) and maintains contact with client, community case managers and service providers to monitor effectiveness of case management plan in achieving outcome objectives and ensure continuity of care.
• Updates and revises case management plans in collaboration with client, case management team, physician, and other providers whenever indicated.
• Documents all patient‑related activities within 8 hours of encounter.
• Acts as a client advocate for the development of community resources.
• Maintains a directory of available and needed services by geographical area and keeps other team members informed about new services.
• Consults with agency clinical staff and other members of client or patient case management team and other service providers to identify potential community resources for resolving client health, psychosocial, or financial problems.
• Collaborates with appropriate personnel and agencies to develop community resources.
• Maintains liaison with Ryan White HIV consortium and provides benefits advocacy services when requested.
• Participates in community and professional education programs on CAP related topics when…