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