Manager

• Ensure the provision of Person-Centered Planning for all service delivery.
• Conducts outreach and engagement activities to engage members in care management.
• Conducts comprehensive assessment and reassessments within the required timeframes for acuity level of member.
• Facilitates the completion of the care plan, as well as ISP for Innovation Waiver services for members receiving waiver services, inclusive of crisis and safety plan.
• Makes referrals to community resources for primary and specialty medical care, physical well-being, mental health.
• Monitor notification of admissions and discharges of ER and hospitalizations.
• Coordinate members’ medication reviews and reconciliation.
• Facilitate proactive planning for transitional care support (pre-discharge).

TLC

Care Manager