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Under direct and indirect supervision, provides outreach to reengage identified clients with Tailored Care Management (TCM) services. The responsibilities of the Care Management Reengagement Specialist include but are not limited to, the following: Care Management Outreach/Engagement Performs outreach to identified clients to successfully reengage them in Tailored Care Management (TCM) Utilize various communication methods to engage clients including phone, tele-health, patient portal, letters, etc. Provide education to clients on benefits of TCM Gather and key in important client data to schedule follow up appointments. Successfully link clients to center care management staff to begin care management assessment. Ensures all reengagement activities are appropriately documented in Care Management dashboard Provide administrative support to centers as needed. May answer phone calls, transfer to appropriate parties, is courteous to public. May file, release, and copy protected healthcare information. Care Management Assessment Documents the client’s service needs, strengths, resources, preferences, and goals to develop a Care Management Plan. Gathers information regarding all aspects of the recipient, including medical, physical, psychosocial, behavioral, financial, social, cultural, environmental, legal, and vocational/educational areas. Integrates all current assessments including the comprehensive clinical assessment and medical assessments, including assessments and information from the HIE/Tailored Plan and the primary care or specialty care physician. Includes early identification of conditions and needs for prevention and amelioration. Consults with other natural and paid supports such as family members, medical and behavioral health providers, and educators to form a complete assessment. Care Management Plan/Documentation Ensures that person centered information is gathered and that the consumer’s health and safety risks are assessed prior to the development of the care management plan Works in conjunction with the client, family, friends, and providers who have lengthy experience with the person. Performs periodic revision of a plan based on the information collected from the person, family, other personal supports, and comprehensive clinical assessments or reassessments. Assist the person to obtain the outcomes/skills/symptom reduction that they desire. Contact the primary care physician to obtain clinical information pertinent to establishing person centered goals. Facilitates provider choice process, maintaining objectivity and providing fact-finding assistance. Ensures that signed Authorization to Disclose Health Information forms are obtained and on file in the consumer’s medical record prior to releasing any information when needed (Substance Use Disorders). Ensures that all information released/disclosed is documented on the Accounting of Release and Disclosure form (this includes documenting any documents given to consumer/legal guardian).
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Career Level
Mid Level
Education Level
Associate degree

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