Care Manager - Hybrid

Position Description

The Care Manager has overall day-to-day responsibility for coordinating the activities of the care team for clients with complex medical and/or psychiatric conditions and for facilitating clients’ access to the full range of medical and psychosocial services efficiently and effectively. The Care Manager is mainly responsible for coordinating medical care by receiving inpatient and ER admissions of targeted clients. In addition, the Care Manager is responsible for visiting clients during inpatient stays and participating actively in discharge planning and care transition activities. The position currently follows a hybrid schedule.

Essential Job Functions

The following duties are mandatory requirements of the job:

• Complete intakes, assessments, reassessments, and develop care plans.
• Conduct home visits and community follow-ups to monitor services and the client’s status.
• Participate in case conferences with other providers.
• Attend supervisory meetings. 
• Maintain contact with the client’s extended family and informal support networks.
• Escort clients to/from service provider appointments when necessary.
• Monitor the client’s progress in utilizing services.
• Conduct care coordination with providers/family for written individualized care plans.
• Work closely with the interdisciplinary care team, including PCP, psychiatrist, therapist, residential services, and substance abuse treatment program.
• Review the client’s intake assessment and uses identified needs to coordinate completing the care plan.
• In conjunction with the client, the Care Manager is responsible for identifying potential barriers to care and possible resolutions.
• Conduct outreach to clients via phone and home visits to review care plan goals. 
• Evaluate medication compliance and assess potential barriers to adherence; ensure medication reconciliation is current. 
• Contact clients on discharge from inpatient services and ER or within 24 hours and ensure any follow-up for transitional care. 
• Outreach to clients to facilitate keeping scheduled appointments; arranges for metabolic and periodic preventive screening.
• Ensure that clients and caregivers know test results by facilitating a discussion between the client and physician as necessary.
• Coordinate services between client and extended care team providers to ensure that the integrated care plan is fully implemented.
• Regularly reviews client information from care team members to identify clients requiring outreach and engagement. 
• Provide or arrange self-management/ wellness education to peers and other support groups in the language the client/family prefers. 
• Organize and participate in case of conferences periodically, as necessary.
• Review benefits, entitlements, and housing with the client/family and assist in the application process. Follows up as required to ensure services are approved.
• Responsible for providing a successful/billable core service to all clients in your caseload.
• Assist in crisis intervention.

Other Responsibilities

The following duties are to be performed as assigned by the supervisor:

1. Participate in CQI activities.
2. Participate in conferences, workshops, and other professional development activities to maintain licensure and remain professionally current with advances in the field of expertise.
3. Participate in multidisciplinary task forces, committees, and projects. 
4. Perform other related duties to maintain your caseload in compliance with the Health Home lead’s policy and procedures.

Minimum Qualifications

Education

• Master’s Degree in Social Service preferred or 
• Bachelor’s Degree in Social Services plus two years of relevant experience.

Experience

Preferably 1-3 years of experience in healthcare, social work, case management, or discharge planning. 

Special skills and knowledge

1. Excellent computer skills necessary.
2. Able to use word processing, spreadsheet, and database programs as required by the position.
3. Excellent oral and written communication skills.
4. Excellent interpersonal skills.
5. Good problem-solving, decision-making, and judgment skills.
6. Must read, write and speak English to the extent required by the position.