Temp Specialty Case 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

• 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

• 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.