Summary:
The Health Home Children's Care Manager provides care coordination and support to clients with chronic medical and behavioral health conditions that are also impacted by social determinants of health. Assists clients to navigate social service, community, and healthcare systems.
Responsibilities:
Tracks/ monitors client progress and produces/maintains detailed, accurate and timely case notes.
Performs and maintains effective care management for a caseload of clients, as assigned, from assessment to discharge.
Develops, coordinates and integrates a coordinated care plan in cooperation with the client, the client’s family, and/or the other providers serving the patient. Updates plan at specified intervals, and as needed based on changes in client’s condition / circumstances.
Maintains data and case records as required and prepares necessary reports
Occasionally required to conduct field work
Case conferences with interdisciplinary team including but not limited to PCP, substance abuse treatment team, residential, hospital discharge planners, etc., to coordinate care delivery between all linked providers and client
Facilitates periodic case record reviews and case conferences with all providers serving the client
Provides Health Home Care Management services at community-based locations and within the Sun River health centers
Provides timely and appropriate follow up on newly referred clients
Facilitates enrollment in Benefit and Entitlement programs. Develops linkages and refers patients for additional service supports
Completes comprehensive assessments within the required timeframes. Maintains detailed, accurate and timely case notes. Conducts intakes as needed
Participates and consults with team supervisor in case conferences, staff meetings, and discharge planning meetings to determine if client requires an alternate level of care or is appropriate for discharge.
Maintains updated case records through health home EMR, and coordinates effective electronic communication throughout all provider databases, as needed. Maintains case records in accordance with health home policies/procedures, agency standards and regulatory requirements.
Provides linkage, coordination with, referral to and follow-up with appropriate ongoing service providers, including mental health and medical specialists
Requirements:
Bachelors Degree
1 year of Care Management experience with Children
Additional Details:
Job type: Full Time M-F 9a-5p
Pay: $23-$25