Care Manager PCC( Genesee County)

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 servicesAssess and address health and safety issues as well as barriers to care and treatment including social determinants of healthCollaborate with interdisciplinary team and incorporate input into comprehensive assessment and the person's Life PlanFacilitate, 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 wellbeingAdhere to Incident Management regulations, guidelines, and policies and proceduresCoordinate and ensure access to chronic disease managementFacilitate referrals to clinical and community resources, including planning, implementation, and follow-up for comprehensive care management and transitional careParticipate in internal and external auditsCoordinate and provide access to long-term care supports and servicesEngage families and natural supports in the care coordination processProvide all individuals and families with services that are culturally and linguistically appropriateAdvocate on behalf of the individualPromote self-advocacy and the ability to self-directUse Health Information Technology for documentation, to link services, and facilitate communication among care coordination teamSecure all health records and other protected information with the highest regard to confidentiality and HIPAA laws and regulationsMaintain compliance with all state and federal laws and regulations, Medicaid compliance, and PCC policies and proceduresDocument all services and maintain appropriate records following all established documentation policies and proceduresComplete all required training including annual, ongoing, and educational trainingsPerform all other duties relevant to the position as requested.Knowledge, Skills, and AbilitiesAbility to act quickly, assess and act accordingly in crisis situationsIntermediate technology skills in Outlook, Teams, Word, Excel, online applications as neededUnderstanding use of an EHR systemKnowledge of ethical and professional responsibilities and boundariesDemonstrate professional work habits including dependability, time management, organization, autonomy, and productivitySome positions may require bi-lingual skillsEducation and Experience:Bachelor's degree with two years of relevant experience ORA 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 ORA Master's degree with one year of relevant experience.Physical Requirements/Working Conditions:Ability to sit/stand throughout day to accomplish jobAbility 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 licenseAbility to conduct in-person visits and meetings at individuals homes, communities, schools, and other locations as applicableAbility to work remotely, satellite office locations, and/or primary office locationCorporate 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 policyAct as a professional representative of PCC in regard to appearance, behavior, temperament, communication, language, and dress.