Bilingual I/DD Care Manager (QP)

Role and Responsibilities:   

Duties of the I/DD Care Manager include, but are not limited to, the following:  

Comprehensive Care Management  

• Provide assessment and care management services aimed at the integration of primary, behavioral and specialty health care and community support services, using a comprehensive person-centered care plan which addresses all clinical and non-clinical needs and promotes wellness and management of chronic conditions in pursuit of optimal health outcomes 

• Complete a care management comprehensive assessment within required timelines and update as needed 

• Develop a comprehensive Individual Support Plan and update as needed 

• Provide diversion activities to support community tenure  

Care Coordination 

• Facilitate access to and the monitoring of services identified in the Individual Support Plan to manage chronic conditions for optimal health outcomes and to promote wellness.  

• Facilitate communication and regularly scheduled interdisciplinary team meetings to review care plans and assess progress. 

• Monitors services for compliance with state standards and Medicaid regulations, including home and community-based standards for 1915i services 

• Verify that services are delivered as outlined in ISP and addresses any deviations in services 

Individual and Family Supports 

• Provide education and guidance on self-management and self-advocacy  

• Provide information about rights, protections, and responsibilities, including the right to change providers, the grievance and complaint resolution process, and fair hearing processes 

• Educate members and recipients about the Registry of Unmet Needs, with referral as indicated 

• Utilize person centered planning methods/strategies to gather information and to get to know the members supported 

• Ensure that members/legally responsible persons are informed of services available, service options available, processes (e.g. requirements for specific service), etc.  

• Promote prevention and health through education on the member’s chronic conditions and/or disabilities for the member, family members, and their caregivers/support members 

• Promote culturally competent services and supports.   

Health Promotion  

• Educate and engage the member/recipient and caregivers in making decisions that promote his/her maximum independent living skills, good health, pro-active management of chronic conditions, early identification of risk factors, and appropriate screening for emerging health problems 

• Closely coordinate care with the member’s I/DD, behavioral health, and physical health providers, including in person visits to Emergency Departments and Skilled Nursing Facilities  

• Support medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment 

Transitional Care Management  

• Proactive and intentional care management when the member/recipient is experiencing care transitions (including, but not limited to transitions related to hospitalization, nursing facility, rehabilitation facility, community-based group home, etc.), significant life changes including, but not limited to loss of primary caregiver, transition from school services, etc.) or when a member/recipient is transitioning between health plans.  

• Create and implement a 90-day transition plan as an amendment to the ISP that outlines how services will be maintained or accessed and includes a process to transition to the new care setting and integrate into his or her community.  

Referral to Community/Social Supports  

• Provide information and assistance in referring members/recipients to community-based resources and social support services, regardless of funding source, which can meet identified needs 

• Provide comprehensive assistance securing health-related services, including assistance with initial application and renewal with filling out and submitting applications and gathering and submitting required documentation, including in-person assistance when it is the most efficient and effective approach.  

Time-Limited Care Coordination for Member Excluded from Receiving Tailored Care Management 

• Assist member who are receiving care management from other entities (e.g., CCNC, CAP/C, CAP/DA) with referral/linkage to I/DD services available through the Tailored Plan or Medicaid Direct contract 

• Provide transitional care management  

• Participate in weekly conference with CCNC, as needed, to share information on high-risk members, including members with a behavioral health transitional care need and members with special health care needs, who are receiving care coordination and care management from both entities or require referrals 

• Coordinate with each member’s care manager to the extent the member is engaged in care management through another entity (e.g. PCCM Vendor, Skilled Nursing Facility, CAP/C or CAP/DA, etc.)  

• Share the results of the any assessments completed, the member’s person-centered plan, and the member’s Care Plan (to the extent one exists) with entity providing care management 

• Notify the member’s care manager that the member is undergoing a transition and engage the member’s assigned care manager to assist with transitioning the member into the community, including in the development of the ninety (90) day post-discharge transition plan to the extent there are items within the care manager’s scope.  

• With the assistance of the care management entity, encouraging, supporting, and facilitating communication between primary care providers and the Partners network providers regarding medication management, shared roles in care transitions and ongoing care, the exchange of clinically relevant information, annual exams, coordination of services, case consultation, and problem-solving as well as identification of a medical home for persons determined to have need.  

Other: 

• Assist state-funded recipients apply for Medicaid  

• Coordinate Medicaid deductibles, as applicable, with the member/legally responsible person and provider(s) 

• Proactively monitor documentation/billing to ensure that issues/errors are resolved as quickly as possible 

• Ensure all clinical documentation (e.g. goals, plans, progress notes, etc.) meet state, agency and Medicaid requirements 

• Maintain medical record compliance/quality, as demonstrated by ≥90% compliance on Qualitative Record Reviews   

• Recognizes and reports critical incidents 

• Promotes member satisfaction through ongoing communication and timely follow-up on any concerns/issues 

• Collaborates with providers to ensure accurate/timely submission of authorization requests for all Tailor Plan-funded services/supports 

• Document within the grievance system any expression of dissatisfaction/concern expressed by member/recipient supported or others on behalf of the member/recipient supported 

• Ensure strong leadership to care team for each member/recipient, including effectively communicating with and providing direction to Care Management extenders