Bilingual Care Manager

• Actively engages with individuals receiving care management services through assessment, care coordination, health promotion, and comprehensive transitional care/follow up.
• Documentation of care management assessment, plan and coordinates care with the care team and communicates regularly with care team members and participating in case conferences.

• Makes appropriate referrals to community resources and empowers individuals to be responsible for their own healthcare and personal needs.
• Referrals will focus on behavioral health, physical health, and Social Determinants of Health (SDOH) needs. SDOH needs are related, but not limited, to economic stability, education access and quality, health care access and quality, community connection and engagement, and safety in communities.

• Coordinates follow-up services for individuals with recent inpatient hospitalization or Emergency Department visit within 24 hours of discharge.
• Coordinates after care needs for transitions in care such as release from incarceration, change in housing, or other life transitions.

• Identifies and provides emergency crisis response as necessary and following agency policies related to crisis. Participation in agency on-call structure may be required and in 24:7 crisis response for members.
• Participates in post crisis team debriefing and provides feedback on ways to prevent future crisis for the person served.

• Communicates effectively with individuals receiving services, providers, and other natural support as needed. Provide education regarding services to all parties involved in the care and support of the individual.
• Establishes collaborative relationships with integrated care team members and community resources within the assigned geographical region to improve resource linkage.

• Maintain medical record compliance/quality.
• Ensure timely documentation of Care Coordination activities as required by department policy and procedures.

• Review data to identify and determine appropriateness for services, which includes monitoring utilization, reporting, clinical measurement data and compliance issues.
• Demonstrate knowledge of and comply with all agency policies and procedures, as well as service definitions related to specific program areas. Maintain trainings as required and requested.
• Participates in Quality Improvement (QI) projects, to improve service deliver, costs of care, on an as needed basis.
• Complete all other relevant responsibilities as assigned by the supervisor.

• A bachelor’s degree in a field related to health, psychology, sociology, social work, nursing or another relevant human services area, or licensure as a registered nurse (RN).
• Two years of experience working directly with individuals with behavioral health conditions (if serving members with behavioral health needs)..
• Knowledge of ICD-10 coding system
• Strong understanding of behavior management techniques
• Excellent communication and interpersonal skills
• Ability to work effectively in a team environment
• For care managers serving members with LTSS needs: Two years of prior LTSS and /or HCBS coordination, care delivery monitoring, and care management experience, in addition to the required cited above. (This experience may be concurrent with the two years of experience working directly with individuals with behavioral health conditions, an I/DD, or a TBI, above.)
• Certified Peer Support Specialist and/peer support experience, preferred.

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