Purpose:

Care Manager staff coordinate the care and services to clients who are transitioning from nursing homes and long-term care facilities to the community. Care Management staff must demonstrate leadership and accountability in managing the pre and post transition activities. This includes but is not limited to being able to navigate changes at the system or individual level, the ability to clearly communicate with the interdisciplinary team, Clients, supports and providers, and the ability to advocate for them and resolve conflicts.

 

Essential Responsibilities, include but are not limited to:

• Care Managers will develop an initial comprehensive person-centered      service plan for each client together with periodic updates.
• Care Management staff are responsible for monitoring and      implementing all service plans. This status needs and preferences, to      ensure changes are made where necessary to benefit the client.
• Care Manager will Educate Clients in areas identified in the Service      Plan such as medication management, Healthy lifestyle, psychosocial needs      and Self-Management skills.
• Care Manager will collaborate with the Clients, the      interdisciplinary team members, other providers, health plan, and other      supports to ensure the Service Plan is being appropriately followed.
• Provide linkages to needed treatment (i.e. Substance Use, trauma      treatment, individual therapy
• Facilitate discharge planning with the Client, facility staff,      Medicaid Managed Care health plan care coordinator, family/guardians, and      other key stakeholders.
• Provide brief, supportive goal directed counseling to clients      experiencing difficulty or ambivalence about making choices.
• Aid client in obtaining new living arrangements by accompanying them      on housing searches for potential apartments.
• Facilitate move to the community which includes but is not limited      to assisting with the purchase of household items, arranging      transportation, setting up utilities, applying for SNAP benefits and      transportation assistance.
• Serve as liaison to a clients managed care company ensuring services      and medications are authorized.
• Facilitate and attend medical and psychiatric appointments as      needed.
• Provide post-discharge monitoring in client’s home.
• Implement strategy to aid clients in improving or achieving      independent living skills.
• Care Management staff must engage in ongoing learning and      professional development and seek appropriate certifications as needed.

The requirements listed below represent the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

• Master's degree in social work, psychology, counseling and related Field.
• Three years of experience working with clients who have serious and persistent mental illness, substance use disorders and/or medically complex needs.
• Bilingual in Spanish & English preferred 
• LCSW or LCPC preferred.