Care Manager

Description

Care Management is a service model whereby all of an individual's caregivers communicate and interface so that the patient's needs are addressed in a comprehensive manner. This is done primarily through a 'care manager' who oversees and provides access to all the services an individual needs to assure that they receive everything necessary to prevent hospitalizations, stay healthy, and maintain stability in their home and community.

The Care Manager is ultimately responsible for the overall provision and coordination of services to an assigned caseload. The Care Manager carries an average caseload of 20-25 children presumed to meet eligibility requirements of New York State’s Children’s Health Homes program. The Care Manager uses problem solving strategies to assist families in managing behavioral health crises with their children through care coordination.

The Care Manager guides program enrollees and their caretakers (legal guardians) through the health care system by assisting with identifying providers and community-based supports, developing relationships with service providers, and tracking interventions and outcomes. Responsibilities include gathering and completing assessments to document eligibility and identifying areas requiring supportive services. They work with children, families, and service providers to create a comprehensive Plan of Care, identifying additional service providers as necessary and coordinating the continuing involvement of families and service providers in executing the Plan of Care.

• Completes initial and ongoing needs assessments (Child and Adolescent Needs and Strengths; CANS) to determine the individual’s most appropriate level of care management.
• Responsible for the overall management of the patient’s Individualized Plan of Care. Through the creation of an Individual Plan of Care the Care Manager is able to:
  Coordinate the enrollee’s provision of services including as per their acuity level;
  Support adherence to treatment recommendations;
  Monitor and evaluate a patient’s 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 Managers serving children will be required to have some face-face visits on a consistent schedule as per the mandates of their acuity level (high, medium, or low).
• Meets Care Management documentation requirements in a timely and accurate manner by effectively utilizing designated Care Management Portal (Medicaid Analytics Performance Portal; MAPP) and Electronic Health Records (EHRs) as needed.
• Functions as an advocate for clients within the agency and external service providers.
• Promotes wellness and prevention by linking enrollees with resources and services based on their individual needs and preferences.
• Educate the child/caregiver on care of chronic conditions, immunization, screening and other preventive interventions.
• 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 the individual 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…