Job Summary:

The Care Manager provides services within the Care Management programs, including Health Home Care Comprehensive Care Management, HCBS Basic Plan Support, and State Paid Care Management services. This position may support Willowbrook Class Members.

The core responsibility of the Care Manager is to oversee and coordinate access to services for people with intellectual and developmental disabilities. The Care Manager works with the member, their family and/or representative, and providers to develop, implement, and monitor an integrated and person-centered driven Life Plan, following the completion of a comprehensive assessment process. The Life Plan is the foundation upon which service delivery is built. The Life Plan identifies services that meet medical and behavioral health needs, community, social supports, and other necessary services to support them to live their healthiest and most meaningful life. A key function of this role is being a strong advocate in supporting the member to access needed services to reach their identified goals and live a meaningful and quality life.

Essential Duties and Responsibilities:

• Deliver person-centered care management services in compliance with regulatory standards and in alignment with the agency’s quality management plan, policies, and standard operating procedures.

• Responsible for the completion of a comprehensive assessment/reassessment process.

• Identify gaps in service provision and make referrals when appropriate. Advocate on the member’s behalf, to reach their identified goals and live a meaningful and quality life.

• Develop, implement and monitor member Life Plans within required timeframes, by leading an interdisciplinary team planning process, with the person at the center.

• Develop strategies that address conflict or disagreements in the person-centered planning process and working with the interdisciplinary team to resolve those conflicts in a timely manner.

• Complete all required service documentation with stated timeframes. Ensure all billing critical documentation is present and valid prior to the submission of any billable service documentation.

• Maintain the member’s continued eligibility for care management through the completion of an annual Level of Care (Re)Determination, ensuring OPWDD eligibility is maintained, and enrolling in the Home and Community Based (HCBS) waiver.

• Identify and access benefits and entitlements (Medicaid, Social Security, SNAP, etc.) when a member is eligible. Ensure existing benefits and other entitlements are maintained.

• Ensure a current and accurate information sharing consent is present within the electronic health record and updated as necessary when changes occur or are requested by the member and/or representative.

• Coordinate and provide access to high quality healthcare services, inclusive of medical, behavioral health, specialized services. Provides regular communication, monitoring, and action oriented follow up on critical and acute healthcare needs.

• Identify, coordinate, and provide access to preventative and health promotion services as needed.

• Coordinate transitional care inclusive of appropriate follow up from inpatient to other settings, discharge planning, facilitating transfers within the healthcare system, residential settings and aging out of childhood services to adult services.

• Foster self-determination and community inclusion through linkage and referral to community-based resources related to the members interests, goals and abilities.

• Use health information technology in the delivery of care management services, included but not limited to the use of the electronic health records and programs to facilitate telehealth services for members. Maintain a thorough and accurate electronic health record for all assigned members.

• Support members self -advocacy utilizing a person centered and strength-based approach and as necessary provide advocacy with and on behalf of members to ensure service needs are met to the fullest extent.

• Attend department/team meetings, trainings, supervisions, etc. as scheduled and in accordance with agency practice and policy.

• Complete all required trainings within required timeframes.

• Travel throughout the designated service area to meet with members as needed in alignment with regulatory standards and to ensure identified needs are met. Travel is required to meet with providers, members of the interdisciplinary team, and accompany members where indicated to necessary appointments.

• Identify and follow all incident reporting guidelines and procedures, ensuring the immediate safety of the member.

• Adhere to all policies and standard operating procedures for the delivery of comprehensive care management and ancillary functions of the Care Manager.

• Actively complies with all standards of conduct as determined by – e.g., internal Corporate Compliance Regulations, OPWDD, DOH and the Justice Center.

• Maintain confidentiality in accordance with HIPAA and privacy practices.

• Perform other duties, as assigned.

• Must possess a valid Driver’s License from New York, or a contiguous state (i.e., Connecticut, New Jersey, Pennsylvania, and Vermont) OR must have the ability to take ample public transportation to attend meetings in person in the community and in the office as needed.

Education and Experience:

• A Bachelor of Arts or Science degree with two years of relevant experience, or a license as a Registered Nurse with two years of relevant experience, or a master’s degree with one year of relevant experience.

• Degrees in the field of Health and Human Services, Psychology, Sociology, or related fields are preferred. Work with people with intellectual and/or developmental disabilities, case management, or in the Mental Health or Substance Abuse field, or related experience preferred.

• Must be able to meet members in their homes or other community locations of their choosing.

• Travel to off-site location required. The incumbent must be comfortable driving or using various forms of public transportation to each destination.

• Must reside in New York State, or a contiguous state and the residence must be within 100 miles to the assigned office Hub.

• Proof of a valid driver’s license for standard personal vehicles will be required at the time of hire.

• Proof of valid auto insurance for standard personal vehicles will be required at the time of hire.

• Absolute sense of integrity and personal commitment to serving people with I/DD and their families.

• Excellent interpersonal, public speaking, and written communication skills.

• Ability to work autonomously.

• Demonstrate professionalism, respect, and ability to work in a team environment.

• Absolute sense of integrity and personal commitment to serving people with I/DD and their families.

Physical Requirements:

• Prolonged periods sitting at a desk and working on a computer.

• Ability to climb stairs – Please note that not all member meetings will be held in locations that are ADA compliant.

• Ability to travel in a vehicle or use public transportation for more than one hour.

This is not a remote position. This is a flexible work environment position with a blend of work from home, field work, and regional travel as well as in office expectations.

Whether working from an approved office site, one’s home, or another remote location, each employee is required to follow minimum privacy standards when working in the flexible work environment:

• Employee has access to a password secured WiFi connection and/or ACA/NY Mobile Hotspot.

• Employee is able to secure any printed materials containing individual or employee personal and/or health information, so as no one else in the household will be able to access it.

• Employee is able to conduct phone and video calls in a private area where the conversation cannot be overheard, and their screen is not visible to others.

• Employee is able to conduct their work in a location where personal and health information on a monitor is not visible to others.

Most of the working hours will be Monday-Friday; expected to be flexible with work hours. Certain deadlines and unexpected developments may require work hours during evening and weekends, as well as hours that exceed the standard number of hours.

This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinet, etc. The noise level in the work environment is usually moderate.

Travel to off-site locations is required; therefore, the incumbent must be comfortable driving or using various forms of public transportation to reach destinations.

AAP/EEOC

LIFEPlan provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or genetics. In addition to federal law requirements, the organization complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, training, and all other legally protected classifications.