Elvira Acosta

The Care Manager provides services within the Care Management programs, including Health Home Care Comprehensive Care Management, HCBS Basic Plan Support, and State Paid Care Management services. This position may support Willowbrook Class Members.

The core responsibility of the Care Manager is to oversee and coordinate access to services for people with intellectual and developmental disabilities. The Care Manager works with the member, their family and/or representative, and providers to develop, implement, and monitor an integrated and person-centered driven Life Plan, following the completion of a comprehensive assessment process. The Life Plan is the foundation upon which service delivery is built. The Life Plan identifies services that meet medical and behavioral health needs, community, social supports, and other necessary services to support them to live their healthiest and most meaningful life. A key function of this role is being a strong advocate in supporting the member to access needed services to reach their identified goals and live a meaningful and quality life.

Duties & Responsibilities

• Deliver person-centered care management services in compliance with regulatory standards and in alignment with the agencys quality management plan, policies, and standard operating procedures.
• Responsible for the completion of a comprehensive assessment/reassessment process.
• Identify gaps in service provision and make referrals when appropriate. Advocate on the members behalf, to reach their identified goals and live a meaningful and quality life.
• Develop, implement, and monitor member Life Plans within required timeframes, by leading an interdisciplinary team planning process, with the person at the center.
• Develop strategies that address conflict or disagreements in the person-centered planning process and working with the interdisciplinary team to resolve those conflicts in a timely manner.
• Complete all required service documentation with stated timeframes. Ensure all billing critical documentation is present and valid prior to the submission of any billable service documentation.
• Maintain the members continued eligibility for care management through the completion of an annual Level of Care (Re)Determination, ensuring OPWDD eligibility is maintained, and enrolling in the Home and Community Based (HCBS) waiver.
• Identify and access benefits and entitlements (Medicaid, Social Security, SNAP, etc.) when a member is eligible. Ensure existing benefits and other entitlements are maintained.
• Ensure a current and accurate information sharing consent is present within the electronic health record and updated as necessary when changes occur or are requested by the member and/or representative.
• Coordinates and provides access to high quality healthcare services, inclusive of medical, behavioral health, specialized services. Provides regular communication, monitoring, and action oriented follow up on critical and acute healthcare needs.
• Identifies, coordinates, and provides access to preventative and health promotion services as needed.
• Coordinates transitional care inclusive of appropriate follow up from inpatient to other settings, discharge planning, facilitating transfers within the healthcare system, residential settings and aging out of childhood services to adult services.
• Use health information technology in the delivery of care management services, included but not limited to the use of the electronic health records and programs to facilitate telehealth services for members. Maintain a thorough and accurate electronic health record for all assigned members.
• Attend department/team meetings, trainings, supervisions, etc. as scheduled and in accordance with agency practice and policy.
• Complete all required trainings within required timeframes.
• Travel throughout the designated service area to meet with members as needed in alignment with regulatory standards and to ensure identified needs are met. Travel is required to meet with providers, members of the interdisciplinary team, and accompany members where indicated to necessary appointments.
• Identify and follow all incident reporting guidelines and procedures, ensuring the immediate safety of the member.
• Maintains confidentiality in accordance with HIPAA and privacy practices.
• Adheres to all policies and standard operating procedures for the delivery of comprehensive care management and ancillary functions of the Care Manager.
• Adheres to and upholds ACA/NYs Code of Conduct.
• Perform other duties, as assigned.

Qualifications

• A Bachelor of Arts or Science degree with two years of relevant experience, or a license as a Registered Nurse with two years of relevant experience, or a masters degree with one year of relevant experience.
• Bilingual in Mandarin or Cantonese required.
• Absolute sense of integrity and personal commitment to serving people with I/DD and their families.
• Excellent interpersonal, public speaking, and written communication skills.
• Ability to work autonomously.
• Demonstrate professionalism, respect, and ability to work in a team.

• Schedule and coordinate the assessment process with individuals, families and providers in the home and/or community
• Contact the individual and/or family/caregiver to schedule the appointment at a time and location most convenient to that person
• This include nights and weekends at the person’s request
• Identify if the individual can participate in an interview (full or partial)
• Conduct the interview/observation in person
• Assessment cannot be complete without the person being interviewed or observed
• Utilize a person-centered interview process (e.g
• Conversational style that starts with the person)
• Interview a knowledgeable person(s) as defined by protocol; someone who has known the person for at least 3 months, sees the person on a weekly basis and has seen the person within tight time frame
• Identify and interview additional knowledgeable person(s) to verify information as needed
• Review records available as needed for coding the assessment
• Code the assessment accurately based on training
• Complete all assessments utilizing UAS and MAXEB
• Ensure coding is within the prescribed timeframes of the assessments
• Utilize CHOICES for MAXEB
• Ensure completeness and accuracy of the assessment

• Provide case management services to homeless families in a Tier 2 emergency family shelter
• Works collaboratively with Westchester County Dept
• Of Social Services and other service providers to help families achieve housing goals
• Formulate a housing plan with residents/families to ensure a timely transition to permanent housing and appropriate usage of housing subsidies
• To provide education to families with information, resources and skills to help them secure and maintain permanent housing and to provide crisis intervention service as needed
• Help residents secure moving costs from DSS which may include security deposits, furniture allowance and arrange utility payments
• Refer participants to specific housing opportunities based on eligibility
• Link families with community based providers that are able to meet their long term social supports and services needed
• Maintain accurate written records of services provided to families and all required documentation in accordance with HUD, WCDSS an HMIS requirements
• Maintain geographic and other needed information regarding participants for use in statistical recording through Excel and other data based programs
• Conduct biweekly room inspections and submit and track work orders requested
• Assist participants with completing all necessary paperwork for housing and service opportunities
• Submit accurate timely reports as required

• Provided supervision to 60+ Community Habilitation, Respite and TBI staff monthly at the individual’s home to ensure quality of their performance and individual progress
• Developed and implemented individual’s Individualized Community Habilitation Plans and ISR for TBI
• Communicated with caregivers /advocates/other service providers to ensure individual satisfaction and making adjustments in service plans as needed
• Reported incidents and resolving crisis situations
• Hired, trained, assigned and re-assigned staff as needed

• Provided service coordination for 25 to 30 individuals enrolled in HCBS Waiver
• Ensured individuals stability and progress through coordinated effort of service providers and community supports
• Communicated with caregivers /advocates/other service providers to ensure individual satisfaction and making adjustments in individual service plans as needed
• Reported incidents and resolving crisis situations
• Completed monthly face to face visits for all individuals as required
• Maintained individual charts for compliance within OPWDD’s Policy, Procedure and Regulations