Job Summary:
The Community Based Care Manager collaborates with members of an inter-disciplinary care team (ICT), providers, community and faith-based organizations to improve quality and meet the needs of the individual, natural supports and the population through culturally competent delivery of care and coordination of services and supports. Facilitates communication, coordinates care and service of the member through assessments, identification and planning, and assists the member in creation and evaluation of person-centered care plans to prioritize and address what matters most, behavioral, physical and social determinants of health needs with the aim to improve the of lives our members.
Essential Functions:
Engage the member and their natural support system through strength-based assessments and a trauma-informed care approach using motivation interviewing to complete health and psychosocial assessments through a health equity lens unique to the needs of each member that identify the cultural, linguistic, social and environmental factors/determinants that shape health and improve health disparities and access to public and community health frameworks
Facilitate regularly scheduled inter-disciplinary care team (ICT) meetings to meet the needs of the member
Engage with the member in a variety of settings to establish an effective, professional relationship. Settings for engagement include but are not limited to hospital, provider office, community agency, member's home, telephonic or electronic communication
Develop and regularly update a person-centered individualized care plan (ICP) in collaboration with the ICT, based on member's desires, needs and preferences
Identify and manage barriers to achievement of care plan goals
Identify and implement effective interventions based on clinical standards and best practices
Assist with empowering the member to manage and improve their health, wellness, safety, adaptation, and self-care through effective care coordination and case management
Facilitate coordination, communication and collaboration with the member the ICT in order to achieve goals and maximize positive member outcomes
Educate the member/ natural supports about treatment options, community resources, insurance benefits, etc. so that timely and informed decisions can be made
Employ ongoing assessment and documentation to evaluate the member's response to and progress on the ICP
Evaluate member satisfaction through open communication and monitoring of concerns or issues
Monitors and promotes effective utilization of healthcare resources through clinical variance and benefits management
Verify eligibility, previous enrollment history, demographics and current health status of each member
Completes psychosocial and behavioral assessments by gathering information from the member, family, provider and other stakeholders
Oversee (point of contact) timely psychosocial and behavioral assessments and the care planning and execution of meeting member needs
Participate in meetings with providers to inform them of Care Management services and benefits available to members
Assists with ICDS model of care orientation and training of both facility and community providers
Identify and address gaps in care and access
Collaborate with facility-based healthcare professionals and providers to plan for post-discharge care needs or facilitate transition to an appropriate level of care in a timely and cost-effective manner
Coordinate with community-based organizations, state agencies and other service providers to ensure coordination and avoid duplication of services
Adjust the intensity of programmatic interventions provided to member based on established guidelines and in accordance with the member's preferences, changes in special healthcare needs, and care plan progress
Appropriately terminate care coordination services based upon established case clos