Care Manager
Current* Provide intensive care management services to clients living with chronic illnesses and their families/support systems and advocate aggressively for clients to obtain the full range of needed services and ensures coordination of these services.* Provide direct coaching, education, and advocacy in linking, engaging and retaining clients in services identified in the Plan of Care.* Escort clients to appointments and provide and gather critical information, both in the field and in the office, with the goal of health and wellness promotion and a reduction in preventable negative health or social events.* Elicit the support of all providers involved in a client's care and ensure maximized communication among all parties via face to face contacts, phone calls, emails, case conferences, etc.* Ensures the timely completion of internal and external required assessments (Comprehensive Assessments, HARP Eligibility Assessment, Eligibility and Appropriateness Assessment, etc.). * Ensures the Plan of Care for each enrolled member includes quality SMART goals, interventions and targets. * Responsible for the overall chart compliance of assigned caseload members.* Responsible for coordinating, attending, documenting all provider case conferences.* Participate in quality improvement activities, projects and reviews.* Complete periodic requests for narrative or quantitative data reports for program review.* Maintain and update caseload tracking tool.* Escort clients to entitlement offices to gain, maintain or regain eligibility.* Conduct home visits to members on caseload as needed.* Provide Diligent and Continued Search efforts in order to regain and maintain member engagement.* Provide member referrals to Health Navigator and Outreach team via member referral to HHSA and HHSC. * Coordinate schedule and appointments with Health Navigator to ensure client attendance at appointments or engage in outreach efforts.
