Care Manager; Org Wide); Home-Based Field

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This is a part-time float position primarily within Fond du Lac County, potential travel up to 2 hours within the service region.

The Care Manager, as part of an interdisciplinary team (IDT), serves frail elders, adults with physical disabilities and adults with intellectual/developmental disabilities who are members of Lakeland Care (LCI). The team’s goal is to promote the overall well-being of the members LCI serves by providing high quality, person-centered, outcome-based care.

Under general direction of the Care Management Supervisor, this position provides care management and service coordination to LCI members. As a member of the IDT, the Care Manager arranges for provision of services and supports based on a comprehensive assessment of the member's identified outcomes and needs. The IDT monitors the provision of services based on the member-centered plan per LCI policy and procedures, and Department of Health Services (DHS) contract requirements.

• As part of an interdisciplinary team (which also includes an RN Care Manager and the member and/or legal representative), conduct a comprehensive assessment of the member's outcomes, needs and risks; and conduct a reassessment as the member’s outcomes and/or condition changes.
• Collaborate with the RNCM to coordinate acute and primary care services, care transitions, and related follow-up care.
• Develop, coordinate, monitor and evaluate the members’ outcome-based member-centered plans, considering cost and effectiveness in authorizing services and choosing providers.
• Coordinate care and benefits to ensure a comprehensive support approach, as well as on‑going access to federal and state programs.
• Implement risk mitigation strategies to promote the member’s health, safety and independence while respecting the member’s rights.
• Educate members of their rights to appeal and grieve decisions and processes and facilitate the member's participation in the appeal/grievance process.
• Participate in on‑going training; maintain current knowledge to ensure compliance with Federal and State regulations, LCI policy and procedure and accepted professional standards.
• Create and maintain member records as required by the Department of Health Services (DHS) contract and LCI policy.
• Coordinate and participate in home visits and care conferences involving the member, their supports, and providers to assess and reassess long‑term care needs and coordinate appropriate interventions.
• Participate in the 24‑hour on‑call rotation as needed. Participate in team meetings and internal work groups as required/requested.
• Maintain the confidentiality of member information and protected health information (PHI) as required by State and Federal regulations, including the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

• Certified Social Worker in the State of Wisconsin with a minimum of one (1) year experience working with at least one of the Family Care target populations, or
• A four‑year bachelor’s degree or more advanced degree in Human Services or related field with one (1) year experience working with at least one of the family care populations, or
• A four‑year bachelor’s degree or more advanced degree in any other area than Human Services with a minimum of three (3) years’ experience working with at least one of the Family Care target populations.
• Working knowledge of computers, computer programs, typing, and data entry.
• Ability to access members’ homes which are not required to comply with the ADA regulations.
• Ability to multi‑task and work in a fast‑paced environment.
• Ability to lift up to 25lbs.
• Current driver’s license, acceptable driving record and proof…