Provides Care Management services to support Care Design NYs model of care as well as OPWDD and NYSDOHs regulatory requirements. The care manager is the person responsible for leading a care coordination team and overseeing all care coordination and care management supports and services to assigned participants. Responsibilities include, but are not limited to, assisting the member in developing, implementing, and monitoring person-centered service plans (Life Plans) using participant health risk assessments and other clinical, social, and functional information to meet members needs and preferences. Also, responsible for serving as the lead of the participants Interdisciplinary Team (IDT).
It is critical that the Care Manager understand and incorporate into their approach to their work the following driving forces behind Care Design New Yorks organizational culture:
- Individuals and families are at the center of all we do.
- We work for individuals and families.
- We value what individuals and families have to say.
- We are focused on outcomes that meet individual needs.
- We will be strong advocates and protect individuals rights. Travel is primarily local during the business day.
Duties and Responsibilities
- Responsible for all care management duties and providing comprehensive care coordination including monitoring the Participants Life Plans according to each individuals unique needs and circumstances.
- Applying a person-centered approach, the care manager is responsible for scheduling, leading and actively collaborating with the Participant and IDT to conduct meetings and assessments to ensure the development of a comprehensive Life Plan that reflects the persons needs and desired life goals.
- Utilizing planning tools such as I AM, CQL POMs, the CAS/DDP2, the LOC, the Comprehensive Emergency Plan and other assessments as needed; such as the Environmental Assessment and Care Giver Adequacy Assessment.
- Implement, update, and monitor Life Plans, and facilitate individualized Life Plan reviews and approval processes at a minimum of every six months or when a trigger event occurs.
- Ensure integration of all needed and preferred supports and services (i.e. medical, behavioral, social, habilitation, dental, psychosocial, and community-based and facility-based long-term supports and services, etc.).
- Communicate with IDT, physicians, and other providers at regular intervals to monitor and update Life Plan(s) and to advocate for participant needs and preferences.
- Provide education to participants, caregivers, circles of support, IDTs, and other stakeholders.
- Maintain participant Life Plan and health risk assessment information in secure system and meet all confidentiality requirements.
- Conduct in-person visits in accordance with OPWDD requirements.
- Flexibility in work schedule is required, with some evening and, or weekend hours as needed.
- Promote Care Design NYs mission and values.
- Utilize a person-centered approach supporting individuals preferences and desires to promote reaching their highest level of independence.
- Maintain ongoing contact with the important people in a participants life, as appropriate.
- Ensure timely submission of all documentation (Life Plan, Progress notes etc.) in accordance with regulated time frames.
- Assist Individual to ensure maintenance of entitlements including recertifications. guardianship, informed decision making.
- Care Managers are expected to assist individuals with maintaining benefits such as Social Security, Supplemental Security Income (SSI), Medicaid and Medicare coverage and/or Food Stamps.
- Monitoring benefits for individuals whose representative payee is the agency operating their certified residence and assisting individuals with their benefits, when the individual does not have a representative payee or when the non-residential representative payee requests assistance.
- Assist individuals to resolve problems in living such as housing, utilities, judicial system and general safety.
- Responsible for advocating for and with an individual to ensure informed decision making, informed consent, and guardianship that is appropriately carried out.
- Meet all training requirements on time.
- Report abuse or neglect immediately when observed or reported.
- May be required to provide transportation for individuals based on their unique needs. (ie. Doctors appointments, planning meetings, etc.)
- Other duties as assigned.
- This description of duties and responsibilities is intended to indicate the kind of tasks required of the position. It does not limit or exclude other duties not mentioned here but required for the successful completion of the job.