Join us at  

NextStep Care

– a place where you’ll be valued, recognized and rewarded for the vital work you do each day. We’ll surround you with a strong team and leadership that supports every aspect of your life – both inside and outside of our centers. And you’ll get to practice your passion  in a non-profit, mission-driven organization that’s known for the highest level of care in our communities

SUMMARY

Responsible for serving as the member’s liaison and advocate assisting members and their informal caregivers in accessing services and by coordinating care among multiple providers to ensure needs are met for duration of their length of stay. The role will provide ongoing follow up to determine if both formal and informal care meet the goals of the member’s carepath and maintain optimal health status and community residence.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Coordinates care that is safe, timely, effective, efficient, equitable, and client/member centered.
• Handles case assignments, drafts community-based carepath plans (including both informal and paid care) and reviews member progress toward carepath goals. 
• Advocates for informed decisions by members regarding their status and treatment.
• Develop effective working relationships and cooperates with multiple teams throughout the case management process; may include primary care providers, managed care plans, home and community-based service providers (HCBS), informal caregivers etc.
• Communicates effectively with all members of the team, including formal and informal caregivers. 
• Records and documents case information completely and accurately in accordance with Care Management Services guidelines.
• Collaborate with internal team members, including Program Support Specialists for Care Management Services, to ensure communication for continuity of care for cases assigned.
• Identifies and resolves carepath variances as they occur; consults with internal and external teams as indicated to ensure effectiveness of community carepath.
• Refers members to a wide variety of community resources as indicated, for formal and informal assistance.
• Works to preserve the essential role of family and informal caregivers in assisting members in meeting carepath goals and addressing social risks.
• Promotes quality and cost-effective interventions and outcomes.
• Assesses and addresses member motivational and behavioral barriers to optimal health and function.
• Assists in removing barriers to primary and specialized medical care, to support optimal health and functional status.
• Meets all mandated reporting requirements.
• Takes call on a rotating basis as assigned.

• Maintains and monitors quality through effective collaboration with Quality Assurance and Education Coordinator for Care Management Services and Administrator for Care Management Services.
• Ensures effective implementation of Quality Assurance and Education plans, initiatives and processes.

• Maintains prompt, accurate and secure documentation as it relates to member needs, contacts and plans.
• Ensures appropriate documentation is filed promptly in members’ chart as outlined in operational Care Management Services Guidelines.
• Ensures member information is secure when removed from the assigned location.

• Accurately reports work time and business expenses in accordance with organizational guidelines.
• Provides on-site assistance for all state surveys, unless previously excused by Administrator for Care Management Services.
• Reports corporate compliance concerns appropriately.

• Participates in weekly multidisciplinary team meetings prepared to discuss assigned members and to present new members.
• Participates in weekly staff meetings.
• Participates in all meetings and in-services as required.
• If a Licensed Practical Nurse or Registered Nurse, may be required to perform Assessment Nurse LPN duties as needed.
• Assists with Case Manager duties for other locations as needed.
• Promotes the image and reputation of the System by exhibiting servant leadership and providing direct and open lines of communication.
• Contributes to the work of committees, workgroups, project management, and other collaborative efforts of the System.
• Performs other duties as necessary to ensure the success of the System.

SKILLS AND ABILITIES

• Thorough knowledge of, adheres to current regulations, Personnel and Operational Guidelines and best practices related to the operations of the Elderly and Disabled Waiver Program and the organization.
• Performs all duties of the Case Manager