HealthKeeperz

Manager

• Conduct comprehensive assessments at enrollment, yearly, or during changes in condition
• Develop, update, and facilitate Care Plans derived from assessments
• Utilize person-centered planning, motivational interviewing, and historical review of assessments to identify required supports
• Address Social Determinants of Health (SDOH), disparities, and complex payer issues in the Plan of Care
• Assign interventions/plans of care to Extenders for monitoring and service engagement
• Coordinate with team members for smooth transitions to appropriate levels of care and utilize ADT information to support admissions/transfers/discharges
• Participate in the agency’s twenty-four (24) hour coverage for care management
• Educate members/Legally Responsible Persons about care teams, services, rights, grievance and appeals process, service options, and payer requirements
• Promote customer satisfaction through ongoing communication and timely follow-up
• Ensure adherence to service orders/doctor’s orders, obtain necessary releases/documentation, and submit documentation to payer
• Maintain certifications/licensure and comply with agency policies and procedures
• Evaluate appropriateness of services, implement plan of care through regular assessments, escalate complex cases and report critical incidents
• Attend Behavior Support Plan (BSP) meetings
• Assist individuals/Legally Responsible Persons in choosing service providers objectively
• Collaborate with care team and service providers to develop plans reflecting individual needs and life goals
• Visit members at their living arrangements (home, relative's home, care facility, or other locations) as required
• Report to Tailored Care Management Supervisor and work as part of a multidisciplinary care team providing whole-person care management for Behavioral Health I/DD Tailored Plan beneficiaries

TCM Care Manager

• Conduct initial screenings and comprehensive assessments of patients and families for the CAP program
• Evaluate eligibility for CAP services and identify social service needs
• Develop, update, and educate patients and families on individualized care plans
• Coordinate care with interdisciplinary team members and external providers and initiate referrals to community resources
• Perform regular follow-ups through home visits (averaging 35-40 visits per quarter within a ~30-mile radius of Waynesville, NC) and phone check-ins
• Monitor and document care effectiveness, complete discharge summaries, and maintain accurate records in the E-CAP system
• Review In-Home Aide documentation, re-certifications, and billing codes for compliance and support compliant billing practices
• Provide monthly case management, attend interagency conferences and periodic in-person team and supervisory meetings
• Complete continuing education and state-mandated training, collaborate with the CAP Director on professional goals
• Use personal vehicle for travel; adhere to safety precautions for rural and unpredictable home environments

Case Manager

• Assessments & Planning: Complete patient screenings, identify needs, and create individualized care plans.
• Coordination: Partner with families, providers, and agencies to ensure appropriate services.
• Follow-Up: Conduct home visits (35–40 per quarter), monitor progress, and adjust plans as needed.
• Documentation: Maintain accurate records in the E-CAP system, review aide notes, and support compliant billing.
• Professional Growth: Complete continuing education and stay current with CAP program requirements.
• Hybrid Work & Travel: Hybrid Schedule: Based at the Durham office, with the option to work remotely up to two days per week after onboarding and supervisor approval.
• Field Travel: Regular home visits across Durham County (private homes and occasional facilities).
• Schedule Flexibility: Case Managers set their own visit schedules while meeting program requirements.
• Vehicle Use: Must provide your own transportation; mileage reimbursement is provided.

TCM Care Manager

Case Manager

CAP Case Manager