Acts as a liaison between clients, service providers, contracting agencies and an array of community caregivers to ensure client needs are identified and client is linked to resources. Receives and follows up with referrals to department programs. Contacts client and schedules time for the assessment. Identifies individuals likely to qualify for and need health and social support services as well as case management. Screens and assesses the clients circumstances and resources to determine presumptive eligibility and suitability for participation in identified programs. Collects information during the assessment process about a client's physical, mental, and psychological functioning and informal support system to develop a plan of care. Assessments may focus on any of the following: physical health, mental functioning, ability to perform activities of daily living, social supports, physical environment, and financial resources. Provides case management services and may conduct home visits, which includes assessment, care plan development, identification of adjunct service needs, and connection to and monitoring of services provided. Develops care plans with participants, families, and/or support systems based upon needs identified during the assessment. Identifies all providers, units of service needed, and the cost of each unit, and the frequency of delivery. Contacts formal and informal providers to arrange services specified in the care plan. Facilitates collaborative and cost-efficient interactions among providers that effectively integrate medical, psychological, and social services in order to provide timely, appropriate, and beneficial service delivery to the client. Monitors changes in clients situations and modifies care plans to meet clients needs. Reassesses the patients to help evaluate the progress that has been made toward accomplishing outcomes of the care plan. Provides ongoing and emergency case management to clients. Identifies client needs, support systems, and necessary services to client families. Directs communication among the client, the payer, the primary care provider, and other service delivery professionals. Maintains all required documentation in the client's case records, and participates in the evaluation of service delivery and the quality assurance/quality improvement program. Processes and communicates information regarding community resources and programs and to convey necessary, requested and recommended information to program participants. Advises manager of problems, questions, delays and/or difficult client situations. May participate in outreach activities, which may include participating at health fairs. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.
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Job Type
Full-time
Career Level
Mid Level