Tailored Care Manager
2 weeks ago
HOURS: Full time, Exempt
Job Duties / Responsibilities:
The Tailored Plan Care Manager is an integral part of Coastal Horizons Center's team approach to integrated care for behavioral health and medical care. This role provides direct support to the client through a holistic and collaborative role with the client's multidisciplinary care team and social supports. Care Managers interact with all members of the healthcare team to keep the lines of communication open. Their role is to improve positive client outcomes through linking clients with medication management, coordinating primary and behavioral health care needs, building trust between clients and their practitioners, connecting clients to community resources, enhancing communication and maintaining continuity of care. The TCM will educate, mentor and monitor clients on issues relevant to their care.
Qualifications / Skills:
Required: a bachelor degree in a field related to health, psychology, sociology, social work, nursing or another relevant human services area, or licensure as a registered nurse (RN); Two years of experience working directly with individuals with a behavioral health (BH) condition, an I/DD, TBI, substance use disorder, and/or co-occurring conditions.
Preferred: one year experience providing care management, case management, or care coordination to the population being served; Commissioner for Case Management Certification (CCM); trained to provide evidence-based care coordination, brief behavioral interventions, clinical assessments, and to support the treatments such as medications initiated by the Primary Care Provider (PCP).
ESSENTIAL DUTIES AND TASKS:
- Oversee Care Management services and activities based on care management standards of practice for enrolled populations
- Develop, review and complete comprehensive assessments that are client-centered and considers the total individual, inclusive of medical, biopsychosocial, behavioral, spiritual and cultural needs of the enrolled population, throughout the continuum of care to improve their health outcomes
- Work with clients/caregivers, to identify and address behavioral, social, cultural, and environmental strengths and barriers as it relates to the client's diagnosis, treatment, and access to care
- Implement Care Management interventions, set goals, and develop the plan of care based on transitional care discharge plans/instructions, the comprehensive assessment and client goals
- Implement client-centered plans using therapeutic skills and techniques such as trauma-informed care, motivational interviewing, strengths-based, and solution-focused modalities
- Facilitate and provide education to client/family about clinical diagnosis, medications, available resources, prevention, and risk factors to achieve optimal self-management
- Monitor quality and effectiveness of interventions to the enrolled populations by setting client-centered SMART goals in collaboration with the client's and families' identified goals
- Delegate tasks and referrals to members of the care management team appropriately, accurately, and timely according to established workflows
- Serve as an advocate and liaison among the client/family, community services, primary providers, specialists, and other care team members to coordinate services
- Work collaboratively with multi-disciplinary team members to facilitate achievement of desired health outcomes
- Engage and maintain collaborative relationships with community provider agencies that promote quality care and cost-effective health care utilization
- Maintain appropriate and timely documentation in the Care Management documentation platform, in accordance with organizational policies and procedures
- Abide by company policies and HIPAA regulations
- Attend Coastal Horizons Center meetings, local and regional trainings, and other events as required
- Willingly perform other duties as assigned
- Perform home visits as required by clinical judgment, client needs, and policies and procedures
- Support organizational goals and objectives in meeting performance improvement targets for various initiatives, programs, and standards of care
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