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 of the services an individual needs to assure that they receive everything necessary to prevent hospitalizations, stay healthy, and maintain stability.
The Care Manager is ultimately responsible for the overall provision and coordination of services to assigned caseload. The Care Manager guides program enrollees and their caretakers (legal guardians) through the health care system by assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes.
MAJOR DUTIES & RESPONSIBILITIES:
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.
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 with 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.
Help clients 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
All other duties, as needed, by CCFHH
QUALIFICATIONS & COMPETENCIES:
Education and/or credential requirements:
Bachelors of Arts in Social Work with two years relevant experience.
Relevant expertise and experience in serving children and families in child welfare, developmental disabilities, mental health, healthcare and/or other systems as well as those receiving preventive services.
Care Managers serving extremely high need enrollees will be required to have demonstrated knowledge and understanding of the needs of such children and families as evidenced by additional years of experience, education, or training.
Care Managers assigned to children who have medical fragility must have extensive experience in coordinating their care
Experience providing service coordination and information, linkages, and referrals for community-based services.
MercyFirst is a large social services organization. Our headquarters is located in Syosset, LI, NY. Our mission is helping children and families recover from the effects of child abuse, neglect, domestic violence, substance abuse, & traumatic events. We offer a competitive salary & excellent benefits including medical, dental, life, pension, 4 weeks’ vacation, sick, personal and holiday time. Excellent opportunity.