Case Manager (BPS)

Job Summary:

• Obtains required Care Management enrollment consents from the individual or legal guardian


• Completes initial and ongoing needs assessments (Child and Adolescent Needs and Strengths; CANS) to determine the individual’s most appropriate level of care management.  


• Responsible for the overall management of the patient’s Individualized Plan of Care.  Through the creation of an Individual Plan of Care the Care Manager is able to:


• Coordinate the enrollee’s provision of services including as per their acuity level. 


• Support adherence to treatment recommendations


• Monitor and evaluate a patient’s needs, including prevention, wellness, medical, mental health, care transitions, and social and community services where appropriate.  


• Meets client contact requirements (keeping in mind that caseloads may be “blended”):


• Care Managers serving children will be required to have some face-face visits on a consistent schedule as per the mandates of their acuity level (high, medium, or low). 


• Meets Care Management documentation requirements in a timely and accurate manner by effectively utilizing designated Care Management Portal (Medicaid Analytics Performance Portal; MAPP) and Electronic Health Records (EHRs) as needed


• Functions as an advocate for clients within the agency and external service providers


• Promotes wellness and prevention by linking enrollees with resources and services based on their individual needs and preferences


• Educate the child/caregiver on care of chronic conditions, immunization, screening and other preventive interventions.  


• Helps clients to obtain and maintain public benefits necessary to gain health care services, including Medicaid and cash assistance eligibility, Social Security, SNAP, housing, legal services, employment and training supports, and others. 


• Effectively communicates and shares information with the individual and their families and other caregivers with appropriate consideration for language, literacy and cultural preferences.


• Conducts care planning meetings/conferences and serves as an interdisciplinary team member to effectively provide/coordinate comprehensive and holistic care


• Identifies available community-based resources and actively manages appropriate referrals, access, engagement, follow-up and coordination of services


• In the event of hospital admissions, actively engages in the discharge planning process ensuring that the patient has all recommended post discharge services in place prior to discharge


• Attends and participates in ongoing staff development trainings to enhance skills needed to effectively meet the demands of the Care Manager position