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About the Role
The Care Manager coordinates the activities of the care team for clients with complex medical and/or psychiatric conditions, facilitating access to medical and psychosocial services. This role focuses on coordinating medical care, managing inpatient and ER admissions, and actively participating in discharge planning and care transition activities.
Responsibilities
- Complete intakes, assessments, reassessments, and develop care plans.
- Conduct home visits and community follow-ups to monitor services and client status.
- Participate in case conferences with other providers.
- Attend supervisory meetings.
- Maintain contact with the client’s extended family and informal support networks.
- Escort clients to/from service provider appointments when necessary.
- Monitor the client’s progress in utilizing services.
- Conduct care coordination with providers/family for written individualized care plans.
- Work closely with the interdisciplinary care team, including PCP, psychiatrist, therapist, residential services, and substance abuse treatment program.
- Review the client’s intake assessment and use the identified needs to coordinate completing the care plan.
- Identify potential barriers to care and possible resolutions in conjunction with the client.
- Conduct outreach to clients via phone and home visits to review care plan goals.
- Evaluate medication compliance and assess potential barriers to adherence; ensure medication reconciliation is current.
- Contact clients on discharge from inpatient services and ER or within 24 hours and ensure any follow-up for transitional care.
- Outreach to clients to facilitate keeping scheduled appointments; arrange for metabolic and periodic preventive screening.
- Ensure that clients and caregivers know test results by facilitating a discussion between the client and physician as necessary.
- Coordinate services between the client and extended care team providers to ensure that the integrated care plan is fully implemented.
- Regularly review client information from care team members to identify clients requiring outreach and engagement.
- Provide or arrange self-management/wellness education to peers and other support groups in the language the client/family prefers.
- Organize and participate in case conferences periodically, as necessary.
- Review benefits, entitlements, and housing with the client/family and assist in the application process.
- Follow up as required to ensure services are approved.
- Provide a successful/billable core service to all clients on the caseload.
- Assist in crisis intervention.
- Participate in CQI activities.
- Participate in conferences, workshops, and other professional development activities to maintain licensure and remain professionally current.
- Participate in multidisciplinary task forces, committees, and projects.
- Perform other related duties to maintain caseload in compliance with the Health Home lead’s policy and procedures.
Requirements
- Bachelor’s degree in social services (preferred) and one year of relevant experience (ideally).
- Associate’s degree in Social Services with two to three years of relevant experience.
- Preferably 1-3 years of experience in healthcare, social work, case management, or discharge planning.
Skills
- Excellent computer skills.
- Proficiency in word processing, spreadsheet, and database programs.
- Excellent oral and written communication skills.
- Excellent interpersonal skills.
- Good problem-solving, decision-making, and judgment skills.
- Ability to read, write, and speak English to the extent required by the position.
Location
- Hybrid
Work Type
- Hybrid
Experience Level
- 1-3 years of experience in healthcare, social work, case management, or discharge planning.
Education Level
- Bachelor’s degree in social services
- Associate’s degree in Social Services