Care Manager Extender

Essential Duties and Responsibilities

• Provides care management extender duties, referring and linking to needed services, monitoring/follow up with client and referrals, provide education for health promotion
• Participates in interdisciplinary treatment planning, consultation activities and ensures all involved parties are aware of the plan of care.
• Provides crisis intervention to all participants of TCM and involves crisis services when needed.
• All other duties as assigned by supervisor.

Care Management Documentation

• Works in conjunction with the client, family, friends, and providers who have lengthy experience with the person.
• Assist the person to obtain the outcomes/skills/symptom reduction that they desire.
• Facilitates provider choice process, maintaining objectivity and providing fact-finding assistance.
• Ensures that signed Authorization to Disclose Health Information forms are obtained and on file in the consumer’s medical record prior to releasing any information when needed (Substance Use Disorders).
• Ensures that all information released/disclosed is documented on the Accounting of Release and Disclosure form (this includes documenting any documents given to consumer/legal guardian).

Referral/Linkage

Referral and linkage activities connect a recipient with medical, behavioral, social and other programs, services, and supports to address identified needs and achieve goals specified in the Care Management Plan. Referral and linkage activities include but are not limited to:

• Coordinating the delivery of services to reduce fragmentation of care and maximize mutually agreed upon outcomes.
• Facilitating access to and connecting recipients to services and supports identified in the Person Centered Plan.
• Making referrals to providers for needed services and scheduling appointments with the recipient.
• Assisting the recipient as he or she transitions through levels of care.
• Facilitating communication and collaboration among all service providers and the recipient.
• Assisting the recipient in establishing and maintaining a medical home where needed.
• Assisting the recipient in establishing OBGYN and prenatal care as necessary.

Natural Support / Services Not Funded Through the Tailored Plan

• Assists consumer/legally responsible person in considering and accessing natural community supports such as educational services, transportation, support from friends/family/church, etc.
• Ensures that the consumer gets the best possible treatment and care by carefully coordinating paid supports/services with other resources available in the community.

Monitoring/Follow-Up

Monitoring and follow up includes activities and contacts that are necessary to ensure that the Care Management Plan is effectively implemented and adequately addresses the needs of the recipient. Monitoring activities may involve the recipient, his or her supports, providers, and others involved in care delivery. Monitoring activities helps determine whether:

• Services are being provided in accordance with the recipient’s Care Management Plan;
• Services in the Care Management Plan adequate and effective;
• There are changes in the needs or status of the recipient; and
• The recipient is making progress toward his or her goals.
• Documents monitoring and the actions taken/planned as a result of the monitoring in the consumer’s record.
• Ensures that the monitoring schedule for each consumer is sufficient to assure the health, safety and welfare of the consumer.
• Monitors for progress/lack of progress through observation, interview, and documentation review.

Coordination

• Works closely with the consumer/legally responsible person, provider agencies, and others involved with the consumer’s care and treatment to avoid/resolve scheduling conflicts, duplication of effort, and other problems that hinder effective treatment.
• Assists consumer in obtaining entitlement services whenever possible.
• Monitors the consumer’s continued eligibility for Medicaid and/or NC Health Choice, as applicable, and provides needed assistance to the consumer/legally responsible person in order to ensure that coverage does not lapse.

Units Billed Minimum Requirement

The extender will be assigned contacts to ensure the team meets the following requirements.

Care management contacts for members with behavioral health needs:

• High Acuity: At least four care manager-to-member contacts per month, including at least one in-person contact with the member.
• Moderate Acuity: At least three care manager-to-member contacts per month and at least one in-person contact with the member quarterly (includes care management comprehensive assessment if it was conducted in-person).
• Low Acuity: At least two care manager-to-member contacts per month and at least two in-person contacts with the member per year, approximately six months apart (includes the care management comprehensive assessment if it was conducted in-person).