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Care Manager
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- The incumbent will be responsible for providing intensive case management, which includes assessment, planning, implementation, coordination, monitoring and evaluation of the member’s needs.
- Performs post-discharge assessment to identify member’s post-hospital or post-ED discharge needs including but not limited to: Member’s physical, functional, social and psychological status Member’s cultural and linguistic needs Caregiver resources and available benefits Follow-up provider care and ensuring scheduled appointments Durable medical equipment and supplies Community resources Develops and implements a member’s specific care plan which includes prioritized SMART goals.
- Coordinates care and services with members, members’ family members/representatives and other providers, as appropriate, including Community Supports and LTSS. Conducts face-to-face meetings at settings outside of CalOptima Health’s locations such as in hospitals, skilled nursing facilities, long-term acute care hospitals, recuperative care and in member’s home settings with members, members’ family members/representatives and other providers, as appropriate.
- Facilitates referrals to behavioral health/substance use disorder services and identifies and makes referrals to Long-Term Support Services (LTSS) department, Community Supports and community resources.
- Follows CalOptima Health’s protocol for documenting all case interventions.
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