Care Manager (HARP)

Position Summary

The Care Manager has overall day-to-day responsibility for coordinating the activities of the care team for patients with complex medical and psychosocial needs and for facilitating each patient’s access to the full range of medical and psychosocial services in an efficient and effective manner.

Essential Functions:

• Utilizes approved Health Home clinical tools and technology to prepare initial and ongoing clinical and psychosocial assessments of service needs of identified clients. Confirms acuity level of identified client and tailors care plan accordingly, reassessing as needed.

• Develops, coordinates and integrates a coordinated care plan in cooperation with the client, the client’s family, and/or the other providers serving the patient. Updates plan at specified intervals, and as needed based on changes in client’s condition / circumstances.

• Participate in integrated care efforts with all providers known to the client to monitor the treatment plan and treatment progress

• Performs and maintains effective care management for a caseload of clients, as assigned, from assessment to discharge.

• Tracks/ monitors client progress and produces/maintains detailed, accurate and timely case notes.

• Facilitates periodic case record reviews and case conferences with all providers serving the patient.

• Reviews new cases for completeness of documentation.

• Provides linkage, coordination with, referral to and follow-up with appropriate ongoing service providers.

• Attends planning meetings with service providers to coordinate service plans. Works effectively with interdisciplinary team of providers including PCP, substance abuse treatment, residential, hospital discharge planners, etc., to coordinate care delivery between all linked providers and client

• Maintains updated case records through health home EMR, and coordinates effective electronic communication throughout all provider databases, as needed. Maintains case records in accordance with health home policies/procedures, agency standards and regulatory requirements.

• Participates and consults with team supervisor in case conferences, staff meetings, and discharge planning meetings to determine if client requires an alternate level of care or is appropriate for discharge.

• Performs other duties and participates in special projects, as required.

The above is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of the job it is not to be construed as an exhaustive statement of all the job functions

EDUCATION/EXPERIENCE:

Bachelor’s degree in Health or Human Services related field with 2 years of related work experience required. Masters degree in Health or Human Services related field, preferred. Ability to communicate well with medical providers and support staff. Ability to work well with diverse population. Ability to handle multiple tasks and stressful environment. Ability to work well within the organizational structure. Ability to work flexible hours including some evenings and weekends. Ability to use common office software. (Word, Excel, Power Point). Familiarity with ECW preferred. Effective oral/written/interpersonal communication skills required. Bilingual skills preferred, and may be required as determined by operational needs. Basic computer skills required

COMPETENCIES:

• Accountable/Results-Oriented

• Adaptability/Flexibility

• Business Acumen

• Communications (written and oral)

• Customer Focus

• Initiative/Innovation

• Interpersonal Effectiveness

• Problem Solving

Teamwork and Collaboration