Licensure – Licensed Social Worker/Registered Nurse
Education – Health Sciences/ Nursing degree from accredited school
Experience – Minimum of two (2) years of supervised experience providing services to aging adults and other individuals involved with their care.
Major Functions and Duties:
Assists aging adults, adults with disabilities, and other involved parties to create both short-term and long-term care arrangements. The Care Manager uses extensive knowledge of the costs, quality, access, and availability of community services to advocate on behalf of the client. The Care Manager is able to:
Conduct comprehensive assessment of client’s current functioning, physical and mental status, and overall well-being.
Collaborate with client and involved parties to identify short-term and long-term care needs and goals.
Develop and implement a care plan based on clinical assessment, client-identified strengths, needs and goals.
Provide access to crisis intervention through a 24 hour on-call capacity.
Intervene on behalf of client to address abuse and neglect issues and matters of client’s rights.
Knowledge and Experience:
Conduct comprehensive clinical assessment of client in an organized and timely manner. Offer referrals to quality healthcare providers and community agencies to promote client’s functioning and conserve assets. Review financial, legal, and medical documentation to identify concerns, eligibility for assistance, and need for additional service referrals.
Collaborate with client and involved parties to identify areas of short-term or long-term goals and needs. Develop and implement a client-driven care plan that is functional, affordable, and built upon client’s strengths.
Educate involved parties in understanding client’s needs, barriers to care, relevant cultural factors, and any presenting diagnoses significant to client’s care and well-being.
Develop and maintain ongoing effective relationships with client, family, friends, legal and financial representatives, healthcare providers, and community agencies through collaboration, advocacy, and decision-making regarding the needs of client.
Function as a liaison for long-distance caregivers to ensure continuity of medical services, appropriate psychosocial supports, and continued safety and well-being of client.
Provide crisis intervention and supportive counseling regarding issues of safety, substance abuse, mental health crises, abuse, and neglect.
Plan and coordinate changes to the client’s living environment. Monitor client’s transition to the new environment to identify any changes in physical or psychological well-being.
Document initial assessment and ongoing progress notes in the electronic client record.
Evaluate effectiveness of interventions and treatment approaches provided to clients and modify approach when necessary.
Attend required staff meetings and participate in continuing education as related to the profession.
Represent Lifematters and the care management profession in the community.
Participate in program development and agency quality assurance initiatives.
Working Conditions:
Works primarily in individual client residences. Must provide his/her own transportation to work sites. Maintains contact with the client and responsible party through the use of telephone and email correspondence.
Rotates “on call” duty and carries a smart phone.
Responsible for new referrals as assigned by the Clinical Director.