Job Overview: The role of the Care Manager is to deliver the 6 core services in a person-centered manner to meet the needs of the individual, OPWDD valued outcomes, the objectives of the People First Transformation, and the State requirements.
Essential Responsibilities:
Provide comprehensive, person-centered Care Management services focusing on the 6 core services:
Complete a Comprehensive Assessment for each individual that identifies medical, mental health, chemical dependency, developmental disability, and social service needs.
Develop a Life Plan with the individual, including family, collaterals, and service providers; ensure all parties agree on goals, interventions, and timeframes.
Conduct face-to-face visits as required.
Care Coordination and Health Promotion:
Engage the individual in treatment adherence, monitor and evaluate needs, coordinate care, and develop relationships with the care planning team.
Review and update the Life Plan; initiate changes as needed.
Ensure timely access to medical/behavioral health appointments and link individuals with resources.
Comprehensive Transitional Care:
Assist individuals transitioning between care levels or after critical events; follow up post-discharge; support during crises.
Use Health Information Technology to facilitate collaboration among providers.
Individual and Family Support:
Communicate with individuals and families, ensuring the Life Plan reflects their preferences.
Utilize peer supports and support groups to increase awareness.
Referral to Community and Social Support Services:
Identify resources, manage referrals, engagement, and follow-up.
Ensure the Life Plan includes community-based services aligned with individual needs and goals.
Use of HIT to Link Services:
Meet HIT standards, maintain documentation on the EHR, and adhere to HIPAA and Privacy regulations.
Additional Responsibilities:
Monitor and assist individuals with benefits (Food Stamps, Medicaid, SSI).
Support individuals with P&P related to schooling and relevant issues.
Report any incidents of abuse, neglect, or maltreatment immediately.