Care Manager

The Care Manager (BCM) is an essential member of the CBES Home Care Interdisciplinary Team. BCM works collaboratively with the CBES Team RN and other members of the Interdisciplinary Team and interviews elders for Home Care Services to determine eligibility in homes, hospitals, nursing homes, or different health care settings.  BCM conducts face-to-face or telephonic assessments of elders’ physical, social, emotional, and environmental status within required time frames to determine elders’ unmet needs, identify elders’ goals, and develop a comprehensive service plan to support these goals. BCM completes all home visits and paperwork within guidelines of EOEA regulation and CBES policies.

 ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

•  Conduct initial and periodic face-to-face or telephonic assessments with elders as required by EOEA regulations and CBES Policies
•   Work collaboratively with the CBES Clinical Team, participated in joint assessment with Team RN as needed.
•   With elders’ participation, in collaboration with other members of the Interdisciplinary Team, develop and implement a comprehensive service plan utilizing:
  • Informal support (family, friends, clergy, etc.)
  • Community resources (medical, legal, housing, etc.)
  • Home care purchased services
  • Other available resources
• Coordinate service provision and collaborate with vendors, health care providers, and other human services agencies to ensure service delivery as outlined by a comprehensive service plan, Personal Care plan, and other directives and preferences as stated by elders.
•  Participate in the hospital or Skilled Nursing Facilities discharge meetings as required.
• Conduct wellness check phone calls and/or emergency home visits during emergencies to determine elders’ whereabouts. 
• Identify elders in at-risk situations, including abuse, neglect, and financial exploitation.  Report to and collaborate with appropriate crisis intervention agencies, including Protective Services and Elders at Risk programs, to alleviate abuse, neglect, and other crises.
• Act as an Advocate for the elders. Assist elders with housing issues, public assistance, insurance, financial benefits, long-term care admissions, and legal matters, including identifying needs, locating resources, and completing all applications and paperwork as necessary. Provide access to essential services to elders in the community by translating fictional needs to CBES Intake staff and other community service vendors.
• Refer elders to other appropriate programs, including Medicaid Waiver, Respite, and Managed Care in Housing or other available and appropriate resources.
•  Maintain up-to-date consumers ’records, including progress notes and all other required forms. 
• Complete, file, and submit for review on a timely basis all home care forms, referral forms, and other documents as required by EOEA regulation and the CBES policies.
• Provide translation between CBES staff and non-English-speaking consumers as needed.
• Provide translation of written material, e.g., brochures, letters, forms, etc., when needed.
• Complete, review and submit reports, statistical information, and other administrative paperwork as required by the Home Care Management Team and/or current CBES policies.
• · Participate in the Quality Assurance process of home care service delivery as directed by EOEA regulation and CBES policies, including peer Care review and home visits. Provide feedback on vendor service provision for annual audits.
• · Update professional skills, knowledge of community resources, and gerontological issues. 
• · Keep informed of all current CBES and EOEA regulations, policies, and procedures.
• · Attend Complex Case Review and Focus Group meetings.
• · Meet with CBES Behavioral Health Specialist
• · Attend all required meetings and training.
• · Perform other duties as assigned by CBES Management.
  
  
• QUALIFICATIONS AND KNOWLEDGE:
•  Bilingual Care Managers must be fully fluent verbally and written in English and one of the following foreign languages
• Must have excellent skills in observation, assessment, and problem-solving. 
• The position required strong organizational skills, including the ability to manage time effectively to meet deadlines.
• Must be able to handle diverse responsibilities and work independently.
• Good interpersonal skills, including the ability to relate with elders, caregivers, administration, and the ability to collaborate in an interdisciplinary context are required.
• Effective advocacy skills, including understanding and sensitivity to cultural issues of the target client population.  Basic knowledge of community resources and programs and the ability to empower elders in improving their quality of life.
• Must be able to work in urban, multi-ethnic, and multi-racial neighborhoods.

EDUCATION:

• A Bachelor’s Degree in Human Services, Social Work, Nursing, or equivalent experience and a minimum of three years' experience in the human services field, preferably working with elders. Must have a basic knowledge of gerontological issues.

PHYSICAL REQUIREMENTS OF THE JOB:

• Ability to lift and carry objects frequently weighing up to 10 to 15 pounds.
• Ability to climb stairs.
• Ability to travel to the community to perform visits at consumers’ homes and in other health care settings, such as nursing homes, Adult Day Health Centers, etc.
• Work requires regularly standing, stooping, and bending.