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About the Role
The Care Manager oversees and provides access to all services an individual needs to prevent hospitalizations, maintain health, and ensure stability. This role is responsible for the overall provision and coordination of services to an assigned caseload, guiding program enrollees and their caretakers through the healthcare system.
Responsibilities
- Obtain required Care Management enrollment consents from the individual or legal guardian.
- Complete initial and ongoing needs assessments (Child and Adolescent Needs and Strengths - NY (CANS-NY)) to determine the individual’s most appropriate level of care management.
- Manage the patient’s individualized Plan of Care, coordinating services, supporting adherence to treatment recommendations, and monitoring patient needs.
- Meet client contact requirements, including face-to-face visits on a consistent schedule for children based on acuity level.
- Meet Care Management documentation requirements in a timely and accurate manner using designated portals (MAPP and EHRs).
- Function as an advocate for clients within the agency and with external service providers.
- Promote wellness and prevention by linking enrollees with resources and services.
- Educate the child/caregiver on care of chronic conditions, immunization, screening, and other preventive interventions.
- Assist clients in obtaining and maintaining necessary public benefits for healthcare services.
- Communicate and share information effectively with the individual, families, and other caregivers, considering language, literacy, and cultural preferences.
- Conduct care planning meetings and serve as an interdisciplinary team member.
- Identify community-based resources and manage referrals, access, engagement, follow-up, and coordination of services.
- Engage in the discharge planning process for hospitalized patients to ensure post-discharge services are in place.
- Attend and participate in ongoing staff development trainings.
- Ensure children have periodic evaluations and follow-up treatment for dental, vision, and hearing care according to Medicaid EPSDT guidelines.
- Perform additional activities as requested by leadership.
Requirements
- A minimum of two years of relevant expertise and experience in serving children and families in child welfare, developmental disabilities, mental health, healthcare, or other systems.
- Experience providing service coordination and information, linkages, and referrals for community-based services.
- Care Managers serving high acuity enrollees must have demonstrated knowledge and understanding of their needs through additional experience, education, or training.
- Care Managers assigned to children with medical fragility must have extensive experience in coordinating their care.
- Excellent writing, communication, and organizational skills.
- A passion for serving children and families with special needs.
- Ability to travel to community-based agency offices, participant’s communities, and homes within the assigned catchment area.
- Ability to receive feedback for professional growth and improvement.
- Proven self-management abilities, including meeting deadlines, ensuring compliance with agency policy and procedures, and overseeing complete and timely maintenance of agency records.
Skills
- Care Management
- Needs Assessment
- Plan of Care Development
- Service Coordination
- Documentation
- Advocacy
- Wellness Promotion
- Prevention
- Community Resource Management
- Referral Management
- Discharge Planning
- Communication
- Organizational Skills
- Self-Management
Location
- Community-based agency offices
- Participant’s communities
- Homes within assigned catchment area
Work Type
- Full-time
Experience Level
- Two years of relevant expertise and experience
- Additional years of experience, education, or training for high acuity enrollees
- Extensive experience for medically fragile children
Education Level
- Bachelors of Arts or Science
- Registered Nurse or Licensed Practical Nurse
- Master’s Degree in related field (License preferred)
About the Company
- Care Management is a service model where all of an individual's caregivers communicate and interface to ensure patient needs are addressed comprehensively.