Obtains required Care Management enrollment consents from the individual or legal guardian
Completes initial and ongoing needs assessments (Child and Adolescent Needs and Strengths; CANS) to determine the individual's most appropriate level of care management.
Facilitates solutions to patient care delivery problems and identifies with client any potential barriers to care.
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:
1.Coordinate the enrollee's provision of services including as per their acuity level.
2.Support adherence to treatment recommendations
3.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"):
1.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, medication management, screening and other preventive interventions.
Accompany child and adult as needed to appointments.
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 services
In the event of hospital admissions, actively engages in the discharge planning process ensuring that the patient has all recommended post discharge services in place prior to discharge
Attends and participates in ongoing staff development trainings to enhance skills needed to effectively meet the demands of the Care Manager position
Ensure that child has periodic evaluations and follow up treatment for dental, vision and hearing care, following Medicaid EPSDT guidelines
Handle confidential information in accordance with HIPAA as well as state and federal privacy and confidentiality rules.
Must be able to provide home-based and community based care management services.
All other duties, as needed, by Care Management Agency