Job Overview: The role of the Care Manager is to deliver the 6 core services in a person-centered manner in order to meet the needs of the individual, the OPWDD valued outcomes, the objectives of the People First Transformation, and the State requirements. The Care Manager provides referral and linkage to benefits and services, and in-person visits with members ranging from monthly to bi-annually dependent on the need of each member.

Essential Responsibilities:

Provide comprehensive, person-centered Care Management services focusing on the 6 core services:

• Comprehensive Care Management
  • Complete a Comprehensive Assessment for each individual that identifies medical, mental health, chemical dependency, developmental disability, and social service need
  • Develop a Life Plan with the individual; include family, collaterals, and service providers in fulfillment of the Life Plan; parties should agree with the goals, interventions, and timeframes
  • Caseload size up to a weight of 20, generally 35-40 members, but may vary
  • Conduct face-to-face visits as required (Monthly, Quarterly, or Bi-Annually dependent on regulatory requirement and individual needs of each individual)
• Care Coordination and Health Promotion
  • Engage the individual in the adherence to treatment recommendations, monitor and evaluate individual’s needs; coordinate all aspects of the individual’s care; develop relationship between the care planning team
  • Review and update the Life Plan with the care planning team; initiate changes in care
  • Ensure timely access to appointments for individuals to medical/behavioral health care services; link individuals with resources
  • Collaboration with both internal and external interdisciplinary teams.
  • Instituting recommendations from internal clinical teams
  • Involvement in post-hospital/rehabilitation discharge
• Comprehensive Transitional Care
  • Assist the individual to transition between levels of care, or after critical events, such as: hospital, school, rehabilitation facility, etc., follow up in a timely manner post discharge, support individual during crisis events
  • Use Health Information Technology to facilitate collaboration among all providers
• Individual and Family Support
  • Communicate and share information with individuals and their family/representative, ensure that the Life Plan reflects the individual’s and their family/representative’s preferences
  • Utilize peer supports, support groups to increase family/representative’s awareness
  • Provide monthly contact and engagement with all members/families
  • Follow up to strive for complete member satisfaction with TCC and external services
• Referral to community and social support services
  • Identify available resources and actively manage referrals, engagement, and follow-up
  • Ensure that the Life Plan includes community-based and other social support services that respond to the individual’s needs and preferences and contribute to achieve the individual’s goals
• Use of HIT link services
  • Meet the HIT standards in the delivery of core services and the Life Plan, as described in the manual
  • Maintain written documentation of service delivery and individuals’ information on the Electronic Health Record System while practicing all HIPAA and Privacy regulations

Location: This position is remote, but does require in-person visits. Candidates will need to be able to travel to do these visits via car or public transportation. Caseload to be located in or near identified counties - but is not limited to the counties listed.

This position requires a quiet distraction free environment for working, or the ability to work from one of our regional offices.

Additional Responsibilities:

• Monitoring/Assisting individuals with maintaining benefits (Food Stamps, Medicaid, and SSI)
• Support individuals with P&P related to schooling, and any relevant issues
• Report any incident of abuse, neglect, or maltreatment immediately
• Other duties as assigned/requested

Specific Knowledge, Skills, and Abilities:

• Excellent interpersonal skills, including conflict-management and knowledge of de-escalation techniques
• Advanced ability to effectively communicate in both verbal and written manner
• Computer software skills, particularly skills with Microsoft Suite
• Ability to organize, schedule, and utilize time well
• Capability to analyze situations accurately, prioritize, and take effective action

Required Education, Experience, and Licenses:

• A Bachelor’s degree with two years of relevant experience, OR
• A License as a Registered Nurse with two years or relevant experience, which can include any employment experience and is not limited to case management/service coordination duties, OR
• A Master’s degree with one year of relevant experience
• MSC Service Coordinators prior to July 1, 2018 are “grandfathered” to facilitate continuity of care

This job description is not all inclusive and the employee may be asked to assume additional responsibilities as the need arises.

Truth in Advertising

It's Wednesday. You turn on your computer and while waiting for it to boot up you recall that you
haven’t returned your client Martha’s call from yesterday. She is likely calling about the status of her
SNAP renewal because it’s getting close to the end of the month and she is getting nervous about having
enough money to buy food. You jot down a note‐to‐self to call her back after your Life Plan meeting that
is scheduled for an hour from now

.
Your computer is now ready for you to login, and you type your password. You smile as it logs you in,
recalling yesterday you had an internet outage in your area and had to wait an hour for the service to
come back up, throwing off your plan for the day. As you open your email box your phone lights up and
you see that your coworker Will has sent you a message asking you to call him.

He states he has a question that is very important. In your email you see a message from your supervisor
reminding you that you have 10 days to return the audit tool to her for one of your charts that’s being
audited. You open your outlook calendar to mark the due date so you don’t forget.

You notice that today is the 15th day since another client’s life plan meeting and the post meeting draft
is due. You open the electronic health record system to take a look at the Life Plan you drafted for your
meeting this morning and make some last‐minute adjustments. While doing so you receive a few emails
from those who are attending this morning’s life plan. Despite having sent the link, they cannot find it
and need you to send the meeting link again.

As you start up the virtual meeting await the attendees your phone begins ringing. It’s Mrs. Rosenkrans.
She has been waiting for an update on her application for an adaptive bike which you had applied for a
Family Support Services Grant for. You yourself have reached out twice for an update from the grant
provider, but have no answer.

As the last attendee arrives you realize never did clock in this morning, and write down “clock in” and
“Call Will” and “Update Mrs. Rosenkrans” to your to‐do list while saying “Good Morning, thank you all
for coming today…”

Tri‐County Care values transparency! Care Management is an amazing career, but it’s not right for
everyone. The days go quickly, and you will meet people who will inspire you in ways you can never
begin to imagine, but it’s fast paced and requires a lot of organization and out‐of‐the box thinking. Did
you read this and immediately think of five methods to keep your day straight? This might be the
perfect career for you! If you think you’d be a great fit, please send us your resume!