CARE MANAGER

DUTIES/RESPONSIBILITIES:

Follow all applicable laws and regulations, including VBHCS Code of Conduct and VBHCS Policies and Procedures, to create and maintain a healthcare and business environment that is committed to integrity and ethical conduct.

The Care Manager is expected to follow guidelines and maintain a level of performance consistent with current productivity expectations as stated in attachments A and B of the job description.

General Characteristics of Duties:

Provide care management to adults and children focusing on strengths of individuals and families. Care management services assist individuals in gaining access to and maximizing the benefit of needed medical, social, educational and other support services.  Care Management services as outlined in the TN Health Link model perform six distinct activities:  Comprehensive Care Management, Care Coordination, Referral to Social Supports, Patient and Family Support, Transitional Care and Health Promotion.  Care Management as a service is provided both at the office and within the community as appropriate to the needs being addressed.

1.         Comprehensive Care Management – Initiate, complete, update, and monitor the progress of a comprehensive person-centered care plan (as needed).

2.         Care Coordination – Participate in the patient’s physical health treatment plan as developed by their primary care provider as necessary.  Support scheduling and reduce barriers to adherence for medical and behavioral health appointments.  Proactive outreach and follow up with primary care and behavioral health providers.

3.         Referral to Social Supports – Identify and facilitate access to community supports (food, shelter, clothing, employment, legal, entitlements and all other resources). Communicate patient needs to community partners.  Provide information and assistance in accessing services.

4.         Patient and Family Support – Provide high-touch in-person support to ensure treatment and medication adherence.  Provide caregiver counseling and training.  Identify resources to assist individuals and family supporters.

5.         Transitional Care – Provide additional high touch support in crisis situations.  Participate in development of discharge plan for each hospitalization.  Develop a systemic protocol to assure timely access to follow-up care post discharge.  Establish relationships with other treatment settings.  Communicate and provide education.

6.         Health Promotion – Education the patient and his/her family on independent living skills with attainable increasingly aspirational goals

Other Duties:

1.         Reports / Record keeping

2.         Engagement

• Treat consumers with respect as individuals.
• Connect in a positive manner with consumers, family members and other natural supports.
• Solicit consumer opinions and input.
• Listen and respond with respect.

3.         Promote the Care Management Team

• Actively participate in team process and utilize team resources.
• Meet with team on scheduled staff meetings and discuss any concerns regarding working with consumer, etc.
• Employ good communication skills (listening, reflecting, role model, etc.)
• Report and share information promptly with doctor, team, and others, as appropriate.

EDUCATION / EXPERIENCE

Must have a Bachelor’s degree in a health-related field of counseling, psychology, social work or other behavioral sciences.