We are a home and community brain injury program and currently looking for a Case Manager who will be part of a multi-disciplinary team who assigns, monitors, and organizes cases. They will be directly involved in the lives of their participants, and provide resources and assistance. The case manager must be highly organized, empathetic, compassionate, nonjudgmental, and eager to help vulnerable adults. Utilizing an intensive case management approach, the case manager provides the best quality services for our participants to help them identify and eliminate barriers identify goals, develop skills that increase their ability to live self-sufficiently, and obtain and maintain vocational and avocational pursuits.
Case Manager Duties and Responsibilities
• Conduct an assessment of the participant's health, physical, functional, behavioral, psychological, and social needs, including health literacy status and deficits, self-management abilities and engagement in taking care of own health, availability of psychosocial support systems including family caregivers, and socioeconomic background. The assessment leads to the development and implementation of a client-specific case management plan of care in collaboration with the participant and family or family caregiver, and other essential health care professionals.

• Lead collaboration with health care team, participant, and family or family caregiver, to identify target goals, and securing participant's participation agreement on the target goals and desired outcomes.

• Work with participant, family or family caregiver, primary care provider, other health care professionals and the payer, to identify resources and community-based agents, in order to maximize the participant's health care responses, quality, safety, cost-effective outcomes, and optimal care experience.

• Work in close collaboration with program staff to ensure establishment, treatment progression and measurable outcome.
• Identify barriers to care and client's engagement in own health; addressing these barriers to prevent suboptimal care outcomes.
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• Facilitate communication and coordination among members of the interprofessional health care team, and involve the participant in the decision-making process in order to minimize fragmentation in the services provided and prevent the risk for unsafe care and suboptimal outcomes. This includes team meetings, weekly updates, and monthly team reports.

• Collaborate with other health care professionals and support service providers across care settings, levels of care, and professional disciplines, with special attention to safe transitions of care.

• Work with external case manager to follow up on coordinating care interventions. This may include referrals to community-based support services, consults, and resources across involved health providers and care settings.

• To develop a collaborative relationship with the stakeholders. Create and maintain a cohesive team. Provide support and resources for clients; good working relationship with support networks, stakeholders, and community resources

• Coordinate and document clinical case management and psychosocial services and documents the overall effectiveness of the case management services provided.

• Coordinate and ensure life skills education and support to participants, including but not limited to: budgeting, apartment maintenance (cleanliness, safety, minor repairs, etc.), mental health wellness self- management / mental health recovery living skills (if applicable), relapse prevention (if applicable), healthy lifestyle/living, community resources, parenting/family living skills (if applicable), family reunification and/or development of relevant social support networks.

• Communicating on an ongoing basis with the participant, participant's family or family caregiver, other involved health care professionals and support service providers, and assuring that all are well-informed and current on the case management plan of care and services. Establish and maintain a therapeutic relationship with the participant, family, staff, and community programs/agencies, and formulate case-management treatment goals and plans that address identified needs, stressors and problems.

• Ensure the appropriate allocation, use, and coordination of health care services and resources while striving to improve safety and quality of care, and maintain cost effectiveness on a case-by-case basis.

• Coordinate the education of the participant, the family or family caregiver, and members of the interprofessional health care team about treatment options, community resources, health insurance benefits, psychosocial and financial concerns, and case management services, in order to make timely and informed care-related decisions.

• Counsel and empowering the client to problem-solve by exploring options of care, when available, and alternative plans, when necessary, to achieve desired outcomes.

• Complete indicated notifications for and pre-authorizations of services, medical necessity reviews, and concurrent or retrospective communications, based on payer's requirements and utilization management procedures.

• Assist the participant in the safe transitioning of care to the next most appropriate level, setting, and/or provider. Research and refer participant resources to live safely and independently.

• Strive to promote participant self-advocacy, independence, and self-determination, and the provision of participant -centered and culturally-appropriate care.

• Advocate for both the participant and the payer to facilitate positive outcomes for the participant, the interprofessional health care team, and the payer.

• Establish alignment of goals and expectations to strategically direct rehabilitation team and approach towards desired outcome.

• Timely evaluate the value and effectiveness of case management plans of care, resource allocation, and service provision while applying outcomes measures reflective of organizational policies and expectations, accreditation standards, and regulatory requirements.

• Coordinate and document clinical case management and psychosocial services and documents the overall effectiveness of the case management services provided. Determine the correct course of treatment with the team through timely identification of goals in a timely manner to progressively move the participant's care along the program to attain the overall outcome goals.
• Notify team and external stakeholders of any negative incident occurring with within 24 hours of being informed or aware of the incident, if not sooner. Case Manager will complete a written incident report within 48 hours of notification. Incidents include but are not limited to: death, fire, drug / police raid, suicide / suicide attempt, 911 call (police / fire dept. / paramedics / other), severe medical illness / emergency, severe psychiatric illness / emergency, sexual assault, act of violence by veteran against other(s), abusive behavior by veteran against staff, act of violence by other(s) against veteran, abusive behavior by staff, accident, medication problems or adverse drug reactions, or other untoward events.
• Maintain accurate documentation of case management meetings.
• Gather and organize therapy notes for the month and upload in the iCloud program.
• Work closely with CEO and billing department to communicate start, progress and end of care.
• Communicate with CEO and biller regarding the changes in services or what may affect the charges.

Required Job Skills:
1. Ability to work with a diverse population of adults and children, including those with physical and cognitive disabilities and addictions and those who are in, or need to be in, recovery. Ability to work with clients who have significant barriers to include but not limited to legal barriers. Ability to work independently, with minimal supervision.
2. Ability to conduct a general assessment of the physical, mental, and emotional health of individual participants, and concisely document that assessment. Ability to maintain confidentiality and personal boundaries.
3. Excellent people skills, including the ability to motivate and lead while maintaining a positive cooperative rapport with other staff. Ability to positively engage and motivate challenging clients. Excellent communication skills, including writing that is accurate in grammar, spelling, and punctuation. Develop relationships and collaborative partnerships with representatives in other agencies. Ability to make referrals to services such as housing, services and benefits, educational and employment, financial assistance, and legal advocacy.
4. Ability to organize and interpret data and information relative to clients and program. Ability to form and work within an effective work team. Ability to work in a stressful, multi-task environment and interact with clients in varying states of mental and physical health. Excellent organizational and time management skills. Ability to maintain positive and supportive disposition in the performance of job duties with staff and other service providers.
Qualifications:
Bachelor's or Master's degree in health care, nursing, counseling, social work, or psychology. Bachelor's degree with Two years of college level coursework in related field required. Two years' experience in case management within a social service or employment counseling position required.
Experience working with brain injury participants preferred.
Experience performing outreach and making referrals for services, and broad working knowledge of services within the local area.
Demonstrable knowledge and advocacy of individuals with brain injury issues.
Excellent organizational and time-management skills.
Proficient in Word, Excel and Outlook programs, and familiar with entering data in database programs.
Must have clean DMV record and reliable transportation.
Possesses superb written and spoken communication skills
Excellent interpersonal skills with colleagues, community leaders, policymakers and others
Excellent time management skills; organized and able to prioritize
Motivated to take on additional community involvement projects and solve problems
Comfortable in a fast-paced environment with multiple cases
Able to organize and manage large amounts of files, schedules, dates, and information
Self-directed and able to work without supervision
Comfortable with building personal relationships and dedicated to helping others
Empathetic and supportive with mentorship and leadership skills
Licensed or certified by state board according to regulatory
Proficient computer skills, including Microsoft Office Suite (Word, PowerPoint, and Excel)
Able to travel up to 50 miles meet with participants and at times telephonic

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