Tailored Care Manager-Idd
CurrentFacilitates timely development of the ISP (Individual Support Plan), crisis plan, Risk Support Needs Assessment, and Behavior Support Plan (as applicable)Completion of comprehensive assessmentsConducts outreach and engagement activities to engage members in care managementEnsures needed community-based resources and social support needs are addressed in participant’s ISPConducts comprehensive assessment and reassessments within required timeframes for acuity level of… Show more Facilitates timely development of the ISP (Individual Support Plan), crisis plan, Risk Support Needs Assessment, and Behavior Support Plan (as applicable)Completion of comprehensive assessmentsConducts outreach and engagement activities to engage members in care managementEnsures needed community-based resources and social support needs are addressed in participant’s ISPConducts comprehensive assessment and reassessments within required timeframes for acuity level of memberClosely coordinates care with the member’s IDD/TBI providers, physical health provider(s) and, when appropriate, behavioral health providersMakes announced/unannounced monitoring visits, including nights/weekends as applicableManagement of transitions of care for members moving from one clinical setting to another to prevent unplanned or unnecessary readmissions, ED visits, or adverse outcomesEducates members/families on methodology for budget development, total dollar value of the budget and mechanisms available to modify the individual budget. Educates the member/families on waiver requirements/limits however, ensures services, as requested are outlined in the budget.Individual and Family SupportReferrals to Community and Social SupportsHealth Information Technology/Care Management Platform Show less