Tribal Option Care Management Extender - LTSS

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Regular Full Time Clerical CIHA, CHEROKEE, NC, US

3 days ago Requisition

Primary Function

Care management extenders serve individuals who are eligible for Tailored Care Management, Intellectual Developmental Delays/Traumatic Brain Injury (I/DD/TBI), Long Term Service or Supports (LTSS) or those who are in the Children and Families Specialty Program (CSFP). Members require assistance to help them gain access to necessary care: medical, behavioral, social, community and other services appropriate to their needs. Services include person centered planning, referral and linkage, monitoring and follow-up.

The duties of this position would include, but not limited to, representing care management when working with members, families, caregivers, as well as, other entities where a member may be seeking care, reside or receive services from.

Job Description

• Provide the following care management functions according to CIHA policy: assist with person centered planning; referral and linkage; and monitoring and follow-up.
• Ensuring that the care plan activities are carried out under the direction and/or delegation of the care manager or care manager supervisor.
• When assigned to provide services for adults, or for children and families, the employee will fulfill duties as outlined in EBCI TO policy and procedure for care management related to the specific population served.
• Gather and document necessary information in the EHR and/or the care management platform including medical, physical and functional, psychosocial, behavioral, financial, social, cultural, environmental, legal, and vocational or educational areas.
• Provides documentation of all significant events in Electronic Health Record and/or the care management platform, as prescribed by EBCI TO policies and procedures and quality assurance standards.
• Engage members in the person centered planning process, that is determined by the member’s care plan, to assist them in obtaining the outcomes, skills, and symptom reduction they desire.
• Link clients to needed services and supports.
• Provide timely information to care team members regarding member status, progress and safety.
• Collaborate with the medical staff and other health professional/agencies to facilitate patient care, discharge and follow-up.
• Assist the care team in providing consultation to patient and family in matters directly related to patients' limitations, finances, adjustments to medical condition and ongoing treatment.
• Work with internal and external providers, and the member’s care team, to coordinate discharge planning, follow-up care, and transfers to other health facilities as appropriate.
• Responsible for attending staffing huddles, as an integral component of a care team, participating in the discussion of client data, and the formulation changes to the care plan/ISP.
• Participate in meetings to review and identify opportunities to improve care provided, and support the team in problem solving when concerns are identified.
• Participate in and assist with facilitating written, telephonic and face-to-face consultation services to various persons and organizations which affect the member. These include schools, courts, probation officers, physicians, hospitals, medical care providers, law enforcement officers, social services, community agencies, etc.
• Provide support tomembers in the office setting, as well as, the community setting by participating in the conducting of home visits with patients and staff, as needed.
• Collect and report on data necessary for member care according to procedure and as directed by supervisor.
• Arrange to visit the member in the new care setting after discharge/transition.
• Performs general outreach, engagement, and follow-up with members;
• Provide coordination of services/appointments (e.g., appointment/wellness reminders, arranging transportation).
• Participate in health promotion activities (as defined in the Tailored Care Management Provider Manual) and knowledge sharing.
• Shares…