Case Manager

Full-time

General Responsibility:

1. Adhere to Tri-County’s mission statement and Senior & Disabled Adult Services commitment to quality services and access to information and services that assist elders in maintaining independence.
2. Maintain up to date knowledge of community services, resources, relevant research, trends, and resources available. Attending relevant professional development opportunities as requested by the COO (this may require out of state) 
3. Maintain and update professional licensure/certification as required by law and for professional growth
4. Responsible to safeguard and respect the confidentiality and the privacy of individuals. Maintain client confidentiality at all times, including verbal communication and written documentation
5. Assume role as a delegated Medicaid Case Management Provider, under Tri-County Community Action Agency. Adhere to Rhode Island Medicaid Provider agreement. 
6. Maintain complete and accurate consumer files. Ensure all case record documentation is in compliance with state, federal, and agency wide rules and regulations.
7. Act as a resource to clients, and their families by making appropriate referrals, working with outside agencies, and other community members to disseminate information on department service and resources

Specific Responsibilities:

1. Work collaboratively with the client and/or family, the RI Office of Healthy Aging (OHA), Department of Human Services (DHS), Neighborhood Health Plan of RI (NHPRI), physician(s) and other community service providers

2. Comply with, and be subject to, all provisions of the rules, regulations, and standards for certification of case management agencies, including, but not limited to utilizing current tools, forms, databases, complete all necessary documentation as required by OHA, DHS and NHPRI.

3. Overall responsibility for the major components of the case management process, including intake/screening; assessments; care planning; care coordination and service implementation; monitoring; advocacy; reassessment; termination and discharge; and related case management activities for an assigned caseload. 

The duties of this position include, but are not limited to:

• Facilitate access by the consumer to various services available to meet maintain, and improve the functional level and independence of the consumer.
• Ensure the following as related to intake and assessments by:
• Complete initial screening of each assigned potential consumer, refer to other agencies as appropriate. 
• Conduct an assessment of each potential consumer to identify consumers care/service needs and concerns in physical, cognitive, social, emotional, financial, nutritional, environmental domains; and lead to the development of an individualized plan of care and/or service by the case management agency and to a determination of the required level of care by the RI Department of Human Services.
• Utilizing the current RI OHA & NHPRI data management site, assessment Tool(s) and Confidential Release of Information Form(s)
• Interviewing clients, caregivers, authorized representatives in the appropriate community care setting, such as home or other facility.
• Completing program applications and obtaining necessary documentation for said programs. 
• Gathering appropriate information related to the client from a variety of sources, including but not limited to insurance companies, financial planners, attorneys, or sources significant to the client
• Identifying high risk factors, barriers to goals, and strengths that will assist the client in achieving goals
• Ensuring that all reports and/or assessments are clear, accurate, and based on comprehensive data collection
• Entering assessments into the current computer data management systems as mandated by DHS, OHA and NHPRI in a timely manner.

As related to the development and implementation of care plans case managers will:

• Develop a person-centered care plan which facilitates individual choice regarding services and supports and who provides them. The consumer identifies other members they wish to participate in the care. 
• Ensure all goals are measurable, time specific, and attainable. Goals are set by the client, in conjunction with identified decision-makers for the client
• Develop an accurate, written analysis, that identifies a variety of ways to meet the client’s needs
• Identify both private and community resources and incorporating them into the Care Management Plan
• Providing the client and service providers with a copy of the care management plan
• Implement care coordination for clients in a timely fashion as determined by the consumer, referring agency/agencies, and service team, but no less frequently than prescribed by the rules and regulations set forth by DHS, OHA and NHPRI
• Arrange, direct and monitor resources as they are provided to the client
• Obtain necessary authorizations and approvals to ensure appropriate services and reimbursements
• Act as a client advocate being available and accessible for contact by the client or his/her representative or making arrangements for coverage of clients at all times.
• Ensure that clients receive continuity of care/service, taking steps to avoid interruptions of care/service, minimizing transitions for the client, and providing a stable, positive relationship for the client.
• Ensure quality services by gathering information about all resources involved in the client’s plan of care. This may be done through direct observation, telephone or in writing.
• Ensure on-going evaluation and re-evaluation of the Care Management Plan and the services provided through:
• Monitoring the Care Management Plan, at a minimum, according to intervals specified by OHA and DHS & NHPRI.
• Visiting the client, at least twice per year, in the appropriate setting and conducting a face-to-face interview to review established goals and progress in meeting those goals by gathering relevant information
• Attempt by telephone or in-person monthly well-being check ins visits for OHA Community and Assisted Living clients.
• Complete quarterly home visits for NHPRI clients and as needed, post hospitalization visits. 
• Complete annual recertification paperwork and attaching necessary documents in the appropriate database for review. 
• As related to Discharge and Transition;
• Develop discharge/transition plans for consumers with changes in service needs and changes in functional status that prompt another level of care.
• Follow discharge protocol process as established by OHA, DHS, and NHPRI, including client notification, paperwork processing. 
• Document the reason for discharge all related information in the individual record 
• Ensure the collection and management of data as required by DHS, OHA and NHPRI and the policies and procedures established within the Senior & Disabled Adult Services department by accurate documentation of case management activities by entering all client data into the OHA, DHS and NHPRI electronic database systems, while ensuring ongoing maintenance of individual client record.

Required Qualifications:

• Possess a bachelor’s degree, preferably in social work, sociology, nursing, human services, or related field Gerontology Certification if applicable
• Two years’ experience in Case Management, working with older adults and or adults with disabilities. 
• Possess and maintain a valid driver’s license, automobile insurance, and have access to reliable transportation. Be willing to travel. 
• Pass initial and ongoing state and national criminal background check. 
• Meet the agency’s definition of “experience criteria” for a case manager through:
  1. Working knowledge of the provision of health care in a variety of settings, community resources, insurance, and care delivery systems
  2. Possess knowledge of human behavior and aging process
  3. Strong interpersonal communication and written skills
  4. Skills and techniques for crisis intervention and problem solving
  5. Ability to critically analyze and make immediate decisions
  6. Ability to actively listen to the consumer
  7. The ability to initiate and sustain trusting relationships with clients and their families’ 
  8. Skills in time management, organizational development, and planning
  9. Demonstrate ability to be culturally competent
  10. Provision of ongoing guidance and support to elders and their families
  11. Coordination and networking with a wide variety of agencies and professionals involved in providing services to older persons

Competitive Benefit Package: We offer an excellent, competitive salary and benefits package including Health, Dental, Vision, Life, and Disability insurance, as well as a 403b Savings Plan/Pension with an Agency match, Vacation, Sick, Holiday time and access to Agency-sponsored EAP services for employees and their families. Many training opportunities are available that include, but are not limited to various educational experiences, certificate programs, CPR and First Aid training as well as ongoing occasions for additional learning. Tri-County is a qualified entity for employees to access loan repayment opportunities.

Application Process: Please visit our website at www.tricountyri.org to apply and view other current openings. Click on the Career Opportunities link on the bottom of the page.

Tri-County Community Action Agency is an Equal Opportunity and Affirmative Action Employer. Tri-County is committed to treating all applicants and employees fairly based on their abilities, achievements, and experience without regard to race, color, national origin, religion, sex, age, disability, veteran status, sexual orientation, limited English proficiency (LEP), gender identity, or any other classification protected by law.