Care Manager

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The Care Manager’s primary function is to work in partnership with individuals with I/DD to coordinate care and services needed to assist individuals achieve optimal health, wellness, and life goals. The Care Manager provides Health Home core services including comprehensive care management, care coordination and health promotion, comprehensive transitional care, individual and family support, referral to community and social support services, and use of Health Information Technology to link services.

Services are delivered with a person-centered approach aligned with NYS OPWDD Valued Outcomes.

• Conduct comprehensive assessments to identify an individual’s clinical and psychosocial needs, choices, and preferences for services
• Assess and address health and safety issues as well as barriers to care and treatment, including social determinants of health
• Collaborate with interdisciplinary team and incorporate input into the comprehensive assessment and Life Plan
• Develop and maintain a person-centered Life Plan that coordinates and integrates an individual’s clinical and non-clinical healthcare needs and services
• Monitor and facilitate implementation of and provide updates to the Life Plan
• Incorporate health promotion and support opportunities for individuals to achieve and maintain optimal health and wellbeing
• Coordinate and ensure access to chronic disease management
• Facilitate referrals to clinical and community resources, including planning, referrals, and follow-up for transitional care
• Coordinate and provide access to long-term care supports and services
• Engage families and natural supports into the care coordination process
• Ensure all individuals and families receive culturally and linguistically appropriate services
• Advocate on behalf of the individual and promote self-advocacy and self-direction
• Use Health Information Technology for documentation, to link services, and to facilitate communication among the care coordination team
• Secure all health records and other protected information with regard to confidentiality and HIPAA
• Maintain compliance with state and federal laws and regulations, Medicaid, and Agency policies and procedures
• Document all services and maintain appropriate records following established procedures
• Participate in continued training and education; perform other duties as requested

• Ability to assess quickly and act accordingly in crisis situations
• Basic technology skills and understanding of health records
• Knowledge of ethical and professional responsibilities and boundaries
• Demonstrated professional work habits including dependability, time management, independence, and responsibility
• Bachelor’s degree with two years of relevant experience OR an RN with two years of relevant experience OR a Master’s degree with one year of relevant experience

Prime Care Coordination is committed to equal employment opportunity. We recruit, employ, train, compensate, and promote without regard to race, religion, color, national origin, age, sex, disability, protected veteran status, or any other basis protected by applicable federal, state, or local law. We will provide reasonable accommodations for known physical or mental limitations of otherwise qualified employees and applicants with disabilities unless the accommodation would impose an undue hardship.

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