The role of the Care Manager is to deliver the 6 core services in a person centered manner in order to meet the needs of the individual, the OPWDD valued outcomes, the objectives of the People First Transformation, and the State requirements.

　　Essential Responsibilities

　　Provide comprehensive, person centered Care Management services focusing on the 6 core services

　　Comprehensive Care ManagementComplete a Comprehensive Assessment for each individual that identifies medical, mental health, chemical dependency, developmental disability, and social service needDevelop a Life Plan with the individual include family, collaterals, and service providers in fulfillment of the Life Plan parties should agree with the goals, interventions, and timeframesConduct face to face visits as requiredCare Coordination and Health PromotionEngage the individual in the adherence to treatment recommendations, monitor and evaluate individual's needs coordinate all aspects of the individual's care develop relationship between the care planning teamReview and update the Life Plan with the care planning team; initiate changes in careEnsure timely access to appointments for individuals to medical/behavioral health care services link individuals with resourcesComprehensive Transitional CareAssist the individual to transition between levels of care, or after critical events, such as hospital, school, rehabilitation facility, etc, follow up in a timely manner post discharge, support individual during crisis eventsUse Health Information Technology to facilitate collaboration among all providersIndividual and Family SupportCommunicate and share information with individuals and their family/representative, ensure that the Life Plan reflects the individual's and their family/representative's preferencesUtilize peer supports, support groups to increase family/representative's awarenessReferral to community and social support servicesIdentify available resources and actively manage referrals, engagement, and follow upEnsure that the Life Plan includes community based and other social support services that respond to the individual's needs and preferences and contribute to achieve the individual's goalsUse of HIT link servicesMeet the HIT standards in the delivery of core services and the Life Plan, as described in the manualMaintain written documentation of service delivery and individuals' information on the EHR while practicing all HIPAA and Privacy regulationsAdditional Responsibilities

　　Monitoring/Assisting individuals with maintaining benefits (Food Stamps, Medicaid, and SSI)Support individuals with PandP related to schooling, and any relevant issuesReport any incident of abuse, neglect, or maltreatment immediately