- Initially engage BH/IDD Tailored Plan members in Care Management services.
- Maintain frequent contact with members/families, utilizing the member's acuity tier (low, moderate, high) as an indicator of needed frequency of contact.
- Coordinate the member's health care and social services, spanning physical health, behavioral health, I/DD, TBI, LTSS, and pharmacy services and services to address unmet health-related resource needs
- Follow up on referrals and work with other healthcare providers serving the member
- Coordinate resources during any crisis event
- Provide assistance in scheduling and preparing members for appointments
- Provide referral, information, and assistance in obtaining and maintaining community-based resources and social support services.
- Ensure that the member has an annual physical exam or well-child visit.
- Monitor progress toward care plan goals through face-to-face and collateral contacts with the member and his or her support member(s) and routine care team reviews.
- Provide medication monitoring, including regular medication reconciliation.
- Manage care transitions for members under care management transitioning from one clinical setting to another, with special focus on transitions out of state psychiatric hospitals, psychiatric residential treatment facilities (PRTFs), and residential treatment levels II-IV.
- Identify members at risk of entry into an institutional setting, such a psychiatric hospital or psychiatric residential treatment facility, and attempt diversion.
Assessment & Care Planning
- Develop an initial Care Management Comprehensive Assessment and reassessments as needed and share results with other healthcare providers serving the member.
- Develop a Care Plan for each member based upon the results of the Assessment and in collaboration with the member's Child & Family Team.
- Utilize strategies consistent with a System of Care philosophy for children and youth.
- Maintain working relationships with key community partners, including clinical consultants and social services providers addressing social determinants of health.
- Engage the member's informal supports.
- Work to resolve conflicts and disputes, ensuring that all participants are given a voice.
- Utilize clinical consultants as needed to access expert support appropriate for the needs of the member.
- Participate with the Care Management team to ensure 24-hour coverage for members receiving care management.
- Maintain positive working relationships with agency colleagues, other providers, community agencies, professionals and other stakeholders.
- Collaborate with other AYN Departments to meet consumer and agency goals.
Documentation & Use of Care Management IT System
- Utilize Care Management IT system daily to:
- Complete Comprehensive Care Management Assessment, reassessments, care plans, and crisis plans.
- Monitor for trigger events indicating a need for immediate action on behalf of a member.
- Utilize workflows to plan for and complete necessary actions on behalf of members.
- Monitor prompts to ensure that members are contacted within required timeframes based upon acuity tiers.
- Communicate with members, care team, consultants, and resource providers.
- Document timely all services rendered to or on behalf of members, along with all communications on behalf of the member.
Support Continuous Quality Improvement
- Make recommendations to improve department procedures and increase operational efficiency.
- Monitor trends and identify opportunities for enhancements in service utilization and implementation.
- Ensure completion of required outcome instruments.
· A bachelor's 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); and
· Two years of experience working directly with individuals with behavioral health conditions
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to stand; walk; sit; use hands to finger, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl; and talk or hear. The employee frequently is required to climb or balance. The employee is occasionally required to taste or smell. The employee must frequently move up to 100 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually low.