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.

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
• Conduct face-to-face visits as required

• 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

• 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

• 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 EHR while practicing all HIPAA and Privacy regulations

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

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.

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
• Conduct face-to-face visits as required

• 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

• 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

• 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 EHR while practicing all HIPAA and Privacy regulations

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