Community Based Care Manager Plus

Job Summary:

The Community Based Care Manager Plus collaborates with members of an inter-disciplinary care team (ICT) to meet the needs of the individual, natural supports and the population through culturally competent delivery of care and coordination of services and supports. Identifies needs or opportunities that would benefit from care coordination to include OhioRISE Members. The Community Based Care Manager performs the full scope of care coordination activities and responsibilities for members who need care coordination and are assigned to a CCE, the OhioRISE Plan, and/or CME, or who choose to receive care management from the MCO.

The Care Manager Plus is assigned to a member when the CCE, the OhioRISE Plan, and/or the CME determine the needs of the member are greater than the capability of the entity. The MCO Care Manager and the Care Manager Plus serve as the single point of contact for care coordination.

Essential Functions:

Engage the member and their natural support system through strength-based assessments and a trauma-informed care approach using motivation interviewing to complete health and psychosocial assessments through a health equity lens unique to the needs of each member that identify the cultural, linguistic, social and environmental factors/determinants that shape health and improve health disparities and access to public and community health frameworks

Facilitate regularly scheduled inter-disciplinary care team (ICT) meetings to meet the needs of the member

Engage with the member in a variety of settings to establish an effective, professional relationship. Settings for engagement include but are not limited to hospital, provider office, community agency, member’s home, telephonic or electronic communication

Develop an individualized, person-centered care plan (ICP) in collaboration with the ICT, based on member’s needs and preferences

Identify and manage barriers to achievement of care plan goals

Identify and implement effective interventions based on clinical standards and best practices

Assist with empowering the member to manage and improve their health, wellness, safety, adaptation, and self-care through effective care coordination and case management

Facilitate coordination, communication and collaboration with the member the ICT in order to achieve goals and maximize positive member outcomes

Educate the member/caregivers about treatment options, community resources, insurance benefits, etc. so that timely and informed decisions can be made Employ ongoing assessment and documentation to evaluate the member’s response to and progress on the ICPEvaluate member satisfaction through open communication and monitoring of concerns or issues

Monitors and promotes effective utilization of healthcare resources through clinical variance and benefits management

Verify eligibility, previous enrollment history, demographics and current health status of each member

Completes psychosocial and behavioral assessments by gathering information from the member, family, provider and other stakeholders

Oversee (point of contact) timely psychosocial and behavioral assessments and the care planning and execution of meeting member needs

Participate in meetings with providers to inform them of Care Management services and benefits available to members

Assists with ICDS model of care orientation and training of both facility and community providers

Identify and address gaps in care and access

Collaborate with facility based case managers and providers to plan for post-discharge care needs or facilitate transition to an appropriate level of care in a timely and cost-effective manner

Coordinate with community-based case managers and other service providers to ensure coordination and avoid…