Care Manager PCC

CDS Life Transitions • Geneva, NY • 23h ago

Summary:

The Care Manager's role is to work in partnership with individuals with I/DD, their family/guardian, and providers to coordinate care and services needed to assist individuals achieve optimal health, wellness, independence, community integration and accomplishing goals. The Care Manager is responsible for providing Health Home core services including comprehensive care management, care coordination and health promotion, comprehensive transitional care, individual and family support, referral to community and social support services, and use of Health Information Technology to link services. Care Managers will provide all services with a person-centered approach.

Essential Job Functions:

Conduct comprehensive assessments to identify an individual's clinical and psychosocial needs, choices, and preferences for services

Assess and address health and safety issues as well as barriers to care and treatment including social determinants of health

Collaborate with interdisciplinary team and incorporate input into comprehensive assessment and the person's Life Plan

Facilitate, develop, and maintain a person-centered Life Plan that integrates an individual's personal wants and needs, clinical and non-clinical healthcare related needs, community services, OPWDD services, and natural supports.

Incorporate health promotion and support opportunities for individuals to achieve and maintain optimal health and wellbeing

Adhere to Incident Management regulations, guidelines, and policies and procedures

Coordinate and ensure access to chronic disease management

Facilitate referrals to clinical and community resources, including planning, implementation, and follow-up for comprehensive care management and transitional care

Participate in internal and external audits

Coordinate and provide access to long-term care supports and services

Engage families and natural supports in the care coordination process

Provide all individuals and families with services that are culturally and linguistically appropriate

Advocate on behalf of the individual

Promote self-advocacy and the ability to self-direct

Use Health Information Technology for documentation, to link services, and facilitate communication among care coordination team

Secure all health records and other protected information with the highest regard to confidentiality and HIPAA laws and regulations

Maintain compliance with all state and federal laws and regulations, Medicaid compliance, and PCC policies and procedures

Document all services and maintain appropriate records following all established documentation policies and procedures

Complete all required training including annual, ongoing, and educational trainings

Perform all other duties relevant to the position as requested.

Knowledge, Skills, and Abilities

Ability to act quickly, assess and act accordingly in crisis situations

Intermediate technology skills in Outlook, Teams, Word, Excel, online applications as needed

Understanding use of an EHR system

Knowledge of ethical and professional responsibilities and boundaries

Demonstrate professional work habits including dependability, time management, organization, autonomy, and productivity

Some positions may require bi-lingual skills

Education and Experience:

Bachelor's degree with two years of relevant experience OR

A license as a Registered Nurse with two years of relevant experience, which can include any employment experience and is not limited to case management/service coordination duties OR

A Master's degree with one year of relevant experience.

Physical Requirements/Working Conditions:

Ability to sit/stand throughout day to accomplish job

Ability to enter data, notes, and other documentation into a computer.

Must be able to travel throughout covered territories in Upstate NY as needed.

Must have a valid driver's license

Ability to conduct in-person visits and meetings at individuals homes, communities, schools, and other locations as applicable

Ability to work remotely, satellite office locations, and/or primary office location

Corporate Qualifications/Expectations:

Adhere to all Prime Care Coordination policies and procedures.

Adhere to the Agency Mission, Vision, Shared Values, and Customer Service Standards.

Attend mandatory education and training modules as scheduled; obtain and maintain required certifications.

Maintain all required certifications/training by State regulations and PCC policy

Act as a professional representative of PCC in regard to appearance, behavior, temperament, communication, language, and dress.

Prime Care Coordination is an Equal Opportunity Employer, and as such affirms the right of every person to participate in all aspects of employment without regard to gender, race, color, religion, national origin, ancestry, age, marital status, sexual orientation, pregnancy, disability, citizenship, military or veteran status, gender expression and/or identity, or any other status or characteristic protected by federal, state, or local law.

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