Case Manager
Current-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.-Coordinates 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.-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.
