Primary Function

The individual performs care management to individuals of all ages who have been diagnosed with an IDD (Intellectual & Developmental Disabilities) /TBI (Traumatic Brain Injury), based on the DSM V or subsequent editions. The IDD Care Manager will complete Care Needs Screenings (CNS) as necessary and will be primarily responsible for completing the Comprehensive Assessment on eligible members who have IDD/TBI/LTSS needs. The IDD Care Manager will be primarily responsible for assisting the member develop their care team and the completion of the Care Plan/ISP based on the needs and desires of the member/legally responsible person, team and their support system. Plans will be person centered in nature and reflect all the areas of support needed by the member. The IDD Care Manager will ensure level of care assessments are completed and is responsible for coordinating the member’s whole person care (Physical, Behavioral, pharmacy—BH, IDD, TBI, and Unmet Social or Health-Related Resource Needs, including but not limited to vocational, education, social supports, personal safety, housing and food insecurity).

Job Description (bulleted list

• Complete comprehensive assessments at enrollment, yearly or at changes in condition.
• Develop Plans of Care derived from the completed assessments and make updates annually or more frequently at changes in conditions, needs or supports.
• Assign interventions/plans of care to the Care Worker(s) for monitoring and service engagement activities.
• Address, in the Plan of Care, if member has identified Social Determinants of Health (SDOH), disparities and/or complex payer issues.
• Assist individuals/legally responsible persons (LRP) in choosing service providers, ensuring objectivity in the process.

• Utilize ADT information to respond within hours/minutes as appropriate to support members who are admitted, transferred or discharged from a facility in a timely manner
• Consistently evaluate appropriateness of services and ensure implementation of plan of care and supports through information gathering and assessment at defined frequency of contact based on risk stratification and member wishes.
• Utilize person centered planning, motivational interviewing and historical review of assessments or screenings and other reports to gather information to identify supports needed for the individual.
• Actively collaborate with care team, members supported, and service providers to ensure development of a plan that accurately reflects the individual’s needs and desired life goals
• Submit required documentation to the payor to ensure timely delivery of services

  - and trouble shoots until authorization (if applicable) is obtained. Notifies care team as appropriate of successful authorization or service initiation.

• Schedules initial contact with member to verify accuracy of demographic information Update inaccurate information and periodically checks for updates, notifying appropriate entities of the changes for data correction.
• Completes activities related to Plans of Care
• Coordinate and participate with Supports Intensity Scale (SIS) Team to ensure successful completion of SIS assessment within time frames allotted.
• For facility (ICF, Hospital, PRTF, group homes or SDC) discharges, inform SIS Supervisor that an assessment needs to be scheduled.
• Attend Behavior Support Plan (BSP) meetings to ensure successful implementation of the plan.
• Schedule and facilitate the PCP/ISP meeting.
• Develop and update PCP/ISP
• Participate in other agency planning meetings such as IEPs,504 Plans, Voc Rehab Plans, Judicial proceeds, child and family team meetings.Advocating for the most appropriate least restrictive interventions and supports to meet the desires, wishes and needs of the individual.
• Submit requests for services and purchase orders for products, –supplies, and services covered under the Innovations waiver.
• Coordinate with other team members to ensure smooth transition to appropriate level of care.
• Complete check-in/contact with member and/or legally responsible person (LRP) via home visit, phone or email.
• Complete Home and Community Based Services (HCBS) Notice of Change Form when arranging new HCBS service placement (for Residential Supports, Day Supports, and Supported Employment) with a new provider and submit to Provider Network department to ensure successful transition to provider.
• Update other Care Team members of urgent or pertinent treatment updates
• Recognize and report critical incidents to supervisors.
• Schedule face to face meeting with member/LRP to provide education about care teams, services, needed supports, etc.

• Provide education and support, to individuals and LRP, in learning about and exercising rights, explanation of the grievance and appeals process, available service options, providers available to meet their needs, and payer requirements that may impact service connection and maintenance.
• Escalate complex cases and cases of concern to Supervisor.
• Promote customer satisfaction through ongoing communication and timely follow-up on any concerns/issues.
• Verify ongoing service adherence with member and/or guardian
• Document all applicable member updates and activities per organizational procedure.
• Ensure that service orders/doctor’s orders are obtained, as applicable.
• Obtain releases/documentation and provide to all stakeholders involved.
• Obtain clinical supporting documentation, legal/guardianship verification, and necessary consents to exchange/release information
• Ensure clinical documentation (e.g. goals, plans, progress notes, etc.) meets state, agency documentation standards, and Medicaid requirements.
• Participate and complete all required agency trainings and meetings, as well as all required care management-based trainings from the State, Technical Assistance entity or payor and within required timeframes as assigned.
• Travel to various community locations, other agencies and other outreach destinations as necessary to meet the members’ needs.
• Maintain all certification(s) or licensure required for the position.
• Demonstrate awareness and knowledge of and comply with all agency policies and procedures, as well as state and federal statutes and regulations related to care management.
• Meet at least minimum standards of monthly contacts and demonstrate ability to effectively engage with members.
• Coordinate the member’s health care and social services including behavioral health, I/DD, TBI, LTSS and pharmacy services as well as other SDOH needs.
• Participate in agency’s twenty-four (24) hour coverage around care management providing for coverage for services, consultation or referral as needed and arrange treatment for emergency medical conditions including behavioral health crises. Specifically, coverage will include the ability to share information such as care plans and psychiatric advance directives and coordinate care to place the member in appropriate setting during urgent and emergent events.
• Complete all other relevant responsibilities as assigned by supervisor.

   

  Job Knowledge

• Person Centered Thinking/planning
• Knowledge of using assessments to develop plans of care
• Knowledge of LOC process, SIS for IDD and FASN assessment for TBI
• Knowledge of Medicaid basic, enhanced MHSUD, and waiver benefits plans
• Knowledge of and skilled in the use of Motivational Interviewing and techniques
• Strong interpersonal and written/verbal communication skills
• Conflict management and resolution skills

• Proficient in Microsoft Office products (such as Word, Excel, Outlook, etc.)
• Ability to master care management platforms and review data for decision making and person centered planning
• High level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance.
• Ability to make prompt, independent decisions based upon relevant facts
• Good organizational skills to prioritize duties and work with minimal levels of onsite supervision to consistently meet deadlines

   

  Education/Experience

• A Bachelor’s degree in a field related to health, psychology, sociology, social work, special education, nursing or another relevant human services area, or licensure as a registered nurse (RN) and
• Two years of experience working directly with individuals with an I/DD or a TBI condition(s) and
• For care managers serving members with Long Term Services and Supports (LTSS) needs: two years of prior LTSS and/or HCBS coordination, care delivery monitoring and care management experience, in addition to the requirements cited above. (This experience may be concurrent with the two years of experience working directly with individuals with I/DD or TBI conditions above).

Contact with others

Contacts are with patients, families, hospital personnel, job sites, schools, and community agencies. The care manager must guide a multidisciplinary team. Contacts with patients, families, and agency personnel are to exchange, provide, and obtain information concerning the individual’s physical and psychosocial health care problems, and needs.

The care manager uses teaching and counseling methods to influence and motivate patient and family behavior. Contacts with other health care or related disciplines within the hospital are for the purpose of collaboration and consultation. Tact, courtesy, and professional conduct are required to maintain positive working relationships. Utmost sensitivity and confidentiality is required when dealing with the individual and families.

Confidential Data

The incumbent has access to highly confidential patient medical and personal information. The Privacy Act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical, and all other pertinent information that comes to his/her attention or knowledge. Adherence to HIPAA is mandatory.  The Act carries both civil and criminal penalties for unlawful disclosure of records. Violations of such confidentiality shall be cause for adverse action.

Responsibility for Accuracy

The individual has a positive effect upon the wellbeing of the individual and is responsible for following policies and procedures, which serve as agency guidelines and prevents errors from occurring. Errors can have a negative outcome since the care manager’s performance affects the health, wellbeing, and habilitation of individuals, and

the quality of care provided. Evaluations and observations are used to modify and develop clinically, programmatic appropriate treatment and support plans. Work can be verified or checked by the immediate supervisor, other health care/habilitation providers or systems checks, but usually the responsibility for accuracy relies solely on the care manager.

Mental/Visual/Physical

While in the the primary care/care management office, the work is mostly sedentary, yet requires walking, standing, bending, pushing, and lifting, assisting individuals if needed to transport or change positions of individuals to and from beds, and wheelchairs. These same activities are required in moving equipment and medical supplies on behalf of the individual. The Care manager will be subject to frequent interruptions requiring varied responses, which can cause distractions therefore, the care manager must possess the ability to differentiate and prioritize many tasks at once while not loosing focus on task completion.

The care manager is required to travel to locations of provider services to observe the individual in their place of activity. This includes home, community settings or provider agencies. While observing, the care manager is constantly gathering information about the participation, progress or challenges for updating and documenting in progress notes or care plans.

Resourcefulness & Initiative

It is expected that the care manager will be able to demonstrate the ability to be a self- starter, work with limited direct supervision and be aware of community-based programs and resources necessary to support the member in the IDD community in the area as well as across the State. This individual also needs to understand when they require supervision/support from their supervisor and reach out to get those needs met in a timely manner, seeking case consultation as necessary.

Environment

Must be flexible in working hours. Work is performed in the home setting, within the community and the office/clinic setting. While in the hospital/clinic setting which is responsible for treating patients with a wide variety of medical problems. Incumbent may be exposed to communicable diseases. The care manager is required to comply with Employee Health Program guidelines including current immunization status of identified communicable diseases and safety precautions are sometimes necessary, such as use of personal protective equipment as required by hospital policy. The work environment involves moderate risks of exposure to infectious disease, radiation, electrical hazards, irritant chemicals and explosive gases. Due to the need to make home visits, the care manager may be visiting homes that have the need for environmental upgrades and the amelioration of mold, eradication of pest, etc.

Customer Service

Consistently demonstrates superior customer service skills to patients/customers/members by demonstrating characteristics that align with CIHA’s guiding principles and core values.