Care Manager - LTSS

Assessment & PlanningConducts comprehensive assessments--including physical, psychosocial, and health literacy evaluations--and interprets relevant diagnostic data to identify member and family needs.Applies critical thinking skills to analyze complex cases and determine underlying causes contributing to high costs. Uses these insights to inform individualized transition/treatment plans and address gaps in care delivery.Partners with and empowers the member to develop an actionable care plan that helps prevent avoidable utilization.Collaboration & EducationAssesses educational needs of members and families, ensuring clear and sufficient information is provided.Facilitate effective communication and collaboration with interdisciplinary healthcare teams, including the member, their support person(s), other family members and external stakeholders to develop, implement, and evaluate individualized care plans, and to address systemic challenges in member care.Care Coordination and DeliveryCoordinates a multi-disciplinary team to include but not limited to member's PCP, specialists, the member, caregivers, and other members of the healthcare team to ensure timely access to appropriate medical care, behavioral health care, and servicesCoordinates and monitors activities among internal departments, external community agencies.Quality Improvement & LeadershipEngages in quality improvement initiatives, supports leadership in system-level improvements, analyzes data for program enhancement, and mentors' colleagues to promote best practices.Advocacy & DocumentationAdvocates for members and families across the healthcare continuum and ensures thorough documentation of all care activities.Performs all other miscellaneous responsibilities and duties as assigned or directed#LI-Hybrid