Manager

• Assess member needs in the areas of physical health, mental health, SUD, oral health, palliative care, memory care, trauma-informed care, social supports, housing, and referral and linkage to community-based services and supports
• Oversees the development of the client care plans and goal settings
• Offer services where the member resides, seeks care, or finds most easily accessible, including office-based, telehealth, or field-based services
• Connect clients to other social services and supports that are needed
• Advocate on behalf of the client with health care professionals (e.g. PCP, etc.)
• Utilize evidence-based practices, such as Motivational Interviewing, Harm Reduction, and Trauma-Informed Care principles
• Conduct outreach and engagement activities in order to facilitate linkage to the ECM program and log activity in the Client Relationship Management (CRM) system
• Evaluate client’s progress and update SMART goals
• Provide mental health promotion
• Arrange transportation (e.g., ACCESS)
• Complete all documentation, including outcome measures within the timeframes established by the individual care plans
• Maintain up-to-date patient health records in the Electronic Medical Record (EMR) system and other business systems
• Complete monthly reporting to ensure program compliance
• Attend training as assigned

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