Community Based Care Manager-Indiana Pregnancy Promise

Job Summary:

The Community Based Care Manager - Indiana Pregnancy Promise collaborates with members of an inter-disciplinary care team (ICT) to meet the needs of the individual, natural supports and the population through culturally competent delivery of care and coordination of services and supports. Identifies needs or opportunities that would benefit from care coordination to include pregnant Medicaid members that meet criteria of the Indiana Pregnancy Promise Program. The Community Based Care Manager - Indiana Pregnancy Promise performs the full scope of care coordination activities and responsibilities for members who need care coordination, are pregnant or 90 days postpartum, and have a diagnosis of opioid use disorder, or a history of opioid use disorder, and agree to participation in the program. The Care Manager serves as the single point of contact for care coordination.

Essential Functions:

• Engage the member and their natural support system through strength-based assessments and a trauma-informed care approach using motivation interviewing to complete health and psychosocial assessments through a health equity lens unique to the needs of each member that identify the cultural, linguistic, social and environmental factors/determinants that shape health and improve health disparities and access to public and community health frameworks
• Engage with the member in a variety of settings to establish an effective, professional relationship. Settings for engagement include but are not limited to hospital, provider office, community agency, member’s home, telephonic or electronic communication
• Develop an individualized, person-centered care plan (ICP) in collaboration with the member, based on member’s needs and preferences that also meets the state outlined care plan template
• Identify and manage barriers to achievement of care plan goals
• Identify and implement effective interventions based on clinical standards and best practices
• Assist with empowering the member to manage and improve their health, wellness, safety, adaptation, and self-care through effective care coordination and case management
• Facilitate coordination, communication and collaboration with the member, identified supports, and providers in order to achieve goals and maximize positive member outcomes
• Educate the member/caregivers about treatment options, community resources, insurance benefits, etc. so that timely and informed decisions can be made
• Employ ongoing assessment and documentation to evaluate the member’s response to and progress on the ICP, and follow state guidelines to comply with timeliness of completion
• Evaluate member satisfaction through open communication and monitoring of concerns or issues
• Monitors and promotes effective utilization of healthcare resources through clinical variance and benefits management
• Verify eligibility, previous enrollment history, demographics and current health status of each member
• Completes psychosocial and behavioral assessments by gathering information from the member, family, provider and other stakeholders
• Oversee (point of contact) timely psychosocial and behavioral assessments and the care planning and execution of meeting member needs
• Participate in meetings with providers to inform them of Care Management services and benefits available to members
• Assists with ICDS model of care orientation and training of both facility and community providers
• Identify and address gaps in care and access
• Collaborate with facility-based case managers and providers to plan for post-discharge care needs or facilitate transition to an appropriate level of care in a timely and cost-effective manner
• Coordinate with community-based case managers and other service providers to ensure coordination and avoid duplication of services
• Appropriately terminate care coordination services based upon established case closure guidelines
• Provide clinical oversight and direction to unlicensed team members as appropriate
• Document care coordination activities and member response in a timely manner according to standards of practice and CareSource policies regarding professional documentation
• Continuously assess for areas to improve the process to make the members experience with CareSource easier and shares with leadership to make it a standard, repeatable process
• Document all assessments, data, case conferences, ICPs, and outreach efforts timely follow the state guidelines outlined in program manual
• Access the MCE and state portals and accurately document data required for reporting
• Collaborate with other MCE care management teams in ongoing state lead meetings to review best practices
• Participate in r