Care Manager - Webster, United States - Prime Care Coordination

Description

The Care Managers primary function is to work in partnership with individuals with I/DD to coordinate care and services needed to assist individuals achieve optimal health, wellness, and life goals.

The Care Manager is responsible to provide 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 and that aligns with NYS OPWDD Valued Outcomes.

Essential Job Functions:

Conduct comprehensive assessments to identify an individuals clinical and psychosocial needs, choices, and preferences for servicesAssess and address health and safety issues as well as barriers to care and treatment including social determinants of healthCollaborate with interdisciplinary team and incorporate input into comprehensive assessment and Life PlanDevelop and maintain a person-centered Life Plan that coordinates and integrates an individuals clinical and non-clinical healthcare related needs and servicesMonitor and facilitate implementation of and provide updates as needed to the Life PlanIncorporate health promotion and support opportunities for individuals to achieve and maintain optimal health and wellbeingCoordinate and ensure access to chronic disease managementFacilitate referrals to clinical and community resources, including planning, referrals, and follow-up for transitional careCoordinate and provide access to long-term care supports and servicesEngage families and natural supports into the care coordination processEnsure all individuals and families receive services that are culturally and linguistically appropriateAdvocate on behalf of the individualPromote self-advocacy and the ability to self-directUse Health Information Technology for documentation, to link services, and facilitate communication among care coordination teamSecure all health records and other protected information with the highest regard to confidentiality and HIPAA laws and regulationsMaintain compliance with all state and federal laws and regulations, Medicaid compliance, and Agency policies and proceduresDocument all services and maintain appropriate records following all established documentation proceduresParticipate in opportunities for continued training and educationPerform all other duties relevant to the position as requested.

Knowledge, Skills, and Abilities:
Ability to act quickly, assess and act accordingly in crisis situationsBasic technology skills and understanding of health recordsKnowledge of ethical and professional responsibilities and boundariesDemonstrate professional work habits including dependability, time management, independence and responsibilityEducation and Experience:

Bachelors degree with two years of relevant experience ORA 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 ORA Masters degree with one year of relevant experience.

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