Manage the care of vulnerable populations who have Behavioral, Social, Chronic or Complex Conditions in their homes or other community settings by completing in-person health assessments and coordinating Members care. Provide CMCHP components of Health Management Services, which encompass care management, disease management, health assessments, care plan interventions, and discharge planning. Identify and prioritize Member needs beginning with early identification of health risk criterion, as identified by the Member and the Legal Agent Representative (LAR) to collaborate with the interdisciplinary team, health management services team, the medical home team, and other community based key providers to conduct planning, interventions, evaluations, education and prevention using a customized Individual Service Plan (ISP).
- Requires in-depth professional knowledge and practical/applied expertise in own discipline and basic knowledge of related disciplines within the broader professional field
- Has knowledge of best practices and how own area integrates with others; demonstrates awareness of the industry, including regulatory, evolving customer demands, and the factors that differentiate the organization in the market
- Acts as a resource for colleagues with less experience; may lead projects with manageable risks and resource requirements
- Solves complex problems and takes a new perspective on existing solutions; exercises judgment based on the analysis of multiple sources of information
- Impacts a range of customer, operational, project or service activities within own team and other related teams; works within broad guidelines and policies
- Works independently, receives minimal guidance
- Explains difficult or sensitive information; works to build consensus
JOB SPECIFIC RESPONSIBILITIES:
- Provide a holistic evaluation of the Member's individual dynamics, needs and preferences
- Educate and help provide health-related information to the Member, the Member's LAR, and others in the Member's Support Network
- Help identify the Member's physical, behavioral, functional, and psychosocial needs
- This person will work from home when not completing face-to-face Member’s assessments in the field
- Engage the Member and the Member's LAR and other caretakers in the design of the Member's Individual Service Plan (ISP) that will include the following and not limited to Autism Spectrum Disorder (ASD), Intellectual or Developmental Disability (IDD), Cancer, and Severe mental illness or behavioral health conditions
- Connect and coordinate the Member to covered and non-covered services necessary to meet the Member's identified needs
- Identify early risk factors and conduct ongoing assessments and document in an electronic application
- Collaborate with the Member's medical home (PCP and Specialist) to deliver and coordinate necessary services
- Engage with families that request information regarding a referral to a Nursing Facility or other long-term care facility, and inform the Member and family about options available through home and community-based service programs.
- Reliable transportation to travel in assigned territory
- Indirect - Indicates that the person in the position is responsible for a product (including information) or service that is involved in the patient’s course of care, treatment or service.
- One or more years recent experience as a care manager, home care RN/LMSW/LBSW/LPC, or clinical RN/LMSW/LBSW/LPC experience in acute/rehab/or long term care setting required
- Experience with Medicaid or Medicare preferred
- Community Based Alternatives (CBA) experience preferred
- Fluent in both English and Spanish preferred
Specific Knowledge, Skills and Abilities:
- Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
- Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
- Meet patient and patient family needs; take responsibility for a patient's safety, satisfaction, and clinical outcomes; use appropriate interpersonal techniques to resolve difficult patient situations and regain patient confidence.
- Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
- Develop and use collaborative relationships to facilitate the accomplishment of work goals.
- Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
- Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
- Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
- Effectively manage one's time and resources to ensure that work is completed efficiently.
- Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
- Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self-impose standards of excellence rather than having standards imposed.
- Assimilate and apply new job-related information in a timely manner.
- Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.
- Two-year Associate's degree or equivalent experience required
- Four-year Bachelor's degree or equivalent experience preferred
LICENSES and CERTIFICATIONS:
- RN must be current and unrestricted in the state of Texas required
- CCM certification preferred
- Light - Exerting up to 20 lbs. occasionally, 10 lbs. frequently, or negligible amounts constantly and may require walking or standing to a significant degree.