Reengagement Specialist Care Manager

Essential Duties and Responsibilities

• Performs outreach to identified clients to educate and reengage them in Tailored Care Management (TCM) Services.
• Provides care management assessment/reassessment, development of care management plans, referring and linking to needed services, monitoring/follow up with client and referrals.
• Keys in important client data to schedule appointments. Successfully link clients to center care management for ongoing support.
• May file, release and copy protected healthcare information. Answers phone calls, transfers to the appropriate parties, is courteous to the public.
• All other duties as assigned by supervisor.

Care Management Outreach/Engagement

• Performs outreach to identified clients to successfully reengage them in Tailored Care Management (TCM).
• Utilize various communication methods to engage clients including phone, tele-health, patient portal, letters, etc.
• Provide education to clients on benefits of TCM.
• Gather and key in important client data to schedule follow up appointments.
• Successfully link clients to center care management staff to begin care management assessment.
• Ensures all reengagement activities are appropriately documented in Care Management dashboard.
• Provide administrative support to centers as needed. May answer phone calls, transfer to appropriate parties, is courteous to public. May file, release, and copy protected healthcare information.

Care Management Assessment

• Documents the client's service needs, strengths, resources, preferences, and goals to develop a Care Management Plan.
• Gathers information regarding all aspects of the recipient, including medical, physical, psychosocial, behavioral, financial, social, cultural, environmental, legal, and vocational/educational areas.
• Integrates all current assessments including the comprehensive clinical assessment and medical assessments, including assessments and information from the HIE/Tailored Plan and the primary care or specialty care physician.
• Includes early identification of conditions and needs for prevention and amelioration.
• Consults with other natural and paid supports such as family members, medical and behavioral health providers, and educators to form a complete assessment.

Care Management Plan/Documentation

• Ensures that person centered information is gathered and that the consumer's health and safety risks are assessed prior to the development of the care management plan.
• Works in conjunction with the client, family, friends, and providers who have lengthy experience with the person.
• Performs periodic revision of a plan based on the information collected from the person, family, other personal supports, and comprehensive clinical assessments or reassessments.
• Assist the person to obtain the outcomes/skills/symptom reduction that they desire.
• Contact the primary care physician to obtain clinical information pertinent to establishing person centered goals.
• 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).