GENERAL FUNCTIONS: The Care Manager is a member of the interdisciplinary team providing care management and clinical services to persons with mental or physical illness who are part of the Williams or Colbert Class Membership. Some CM’s may also have a secondary diagnosis of substance abuse, intellectual and/or developmental disabilities or other clinical issues. Must be accessible via cellphone during work hours.

ESSENTIAL FUNCTIONS:

·       Care Managers will manage and provide services to case load of William/Colbert Members

·       Care Managers will be responsible for the development and implementation of comprehensive assessment and service plans for the class members meeting Program Guidelines and deliverables.

·       Conduct on-going assessments of CM’s level of functioning and update care plans including: (1) functional status, (2) risk of harm, (3) medication status, (4) healthcare utilization, (5) psychosocial status, and (6) community engagement as needed.

·       Coordinate and manage all the services each class member needs to achieve their community living goals.

• Care Managers will serve as the class member’s point of contact and case manager for the remainder of the transition process and stay with the class member after they move into the community.
• Care Mangers will be tasked with ensuring access to all the services needed in the service plan with assistance from Transition Coordinator.
• Manage all aspects of medication status evaluation provided by the Medical Care manager and document the class member’s ability to self-manage their medication with Medical Care manager assistance.
• Manage and work with the care team,  transition coordinator to ensure services are coordinated with the  Managed Care Organizations(MCO) as needed, to secure appropriate referrals, linkages, and appointment prior to transition.

• • Care Managers will provide supportive, goal directed counseling to class members to help them make decisions about their transition. They will act as educator, collaborator, and advocate for class members and work closely with the other members of the transition team to ensure a seamless process without bottlenecks or needless delays.

• Achieve required productivity targets and complete documentation in a timely manner, including clinical documentation and service reporting.
• Manage communication with the class members and all collateral supports: including emergency room visits, hospitalizations, and medication changes/adjustments.
• Provide information to outside agencies as requested to coordinate and assure the appropriateness of services.

·       Provide and document crisis interventions as needed, within 24 hours of an incident, and complete an incident report when necessary.

·       Other duties as assigned.