Summary:

The Care Manager's role is to work in partnership with individuals with I/DD, their family/guardian, and providers to coordinate care and services needed to assist individuals achieve optimal health, wellness, independence, community integration and accomplishing goals. The Care Manager is responsible for providing 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. Care Managers will provide all services with a person-centered approach.

Essential Job Functions:

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 comprehensive assessment and the person's Life Plan Facilitate, develop, and maintain a person-centered Life Plan that integrates an individual's personal wants and needs, clinical and non-clinical healthcare related needs, community services, OPWDD services, and natural supports. Incorporate health promotion and support opportunities for individuals to achieve and maintain optimal health and wellbeing Adhere to Incident Management regulations, guidelines, and policies and procedures Coordinate and ensure access to chronic disease management Facilitate referrals to clinical and community resources, including planning, implementation, and follow-up for comprehensive care management and transitional care Participate in internal and external audits Coordinate and provide access to long-term care supports and services Engage families and natural supports in the care coordination process Provide all individuals and families with services that are culturally and linguistically appropriate Advocate on behalf of the individual Promote self-advocacy and the ability to self-direct Use Health Information Technology for documentation, to link services, and facilitate communication among care coordination team Secure all health records and other protected information with the highest regard to confidentiality and HIPAA laws and regulations Maintain compliance with all state and federal laws and regulations, Medicaid compliance, and PCC policies and procedures Document all services and maintain appropriate records following all established documentation policies and procedures Complete all required training including annual, ongoing, and educational trainings Perform all other duties relevant to the position as requested. Knowledge, Skills, and Abilities Ability to act quickly, assess and act accordingly in crisis situations Intermediate technology skills in Outlook, Teams, Word, Excel, online applications as needed Understanding use of an EHR system Knowledge of ethical and professional responsibilities and boundaries Demonstrate professional work habits including dependability, time management, organization, autonomy, and productivity Some positions may require bi-lingual skills

Education and Experience:

Bachelor's degree with two years of relevant experience OR A license as a Registered Nurse with two years of relevant experience, which can include any employment experience and is not limited to case management/service coordination duties OR A Master's degree with one year of relevant experience.

Physical Requirements/Working Conditions:

Ability to sit/stand throughout day to accomplish job Ability to enter data, notes, and other documentation into a computer. Must be able to travel throughout covered territories in Upstate NY as needed. Must have a valid driver's license Ability to conduct in-person visits and meetings at individuals homes, communities, schools, and other locations as applicable Ability to work remotely, satellite office locations, and/or primary office location • Reasonable accommodations may be made to the extent required under applicable law to enable individuals with disabilities to perform the essential functions of this position.

Corporate Qualifications/Expectations:

Adhere to all Prime Care Coordination policies and procedures. Adhere to the Agency Mission, Vision, Shared Values, and Customer Service Standards. Attend mandatory education and training modules as scheduled; obtain and maintain required certifications. Maintain all required certifications/training by State regulations and PCC policy Act as a professional representative of PCC in regard to appearance, behavior, temperament, communication, language, and dress. 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. Prime Care Coordination will make reasonable accommodations for known physical or mental limitations of otherwise qualified employees and applicants with disabilities unless the accommodation would impose an undue hardship on the operation of our business. 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