Care Manager III-Home Care and Support services

The Care Manager III serves a long-standing, discerning clientele with eclectic life experiences who expect excellence, discretion, and individualized attention. This role requires a high level of clinical expertise, interpersonal intelligence, and the ability to provide solution-oriented care management in a dynamic and complex environment. Proactive care coordination is central to the daily duties of this role.

Key Responsibilities:

Client Assessment and Care Planning

• Self-driven individual that can anticipate client changes: social, medical and environmental.
• A true communication diplomat- can address client concerns with firmness and tact. Serving as the subject matter expert for client care; both short term and long-term.
• Conduct comprehensive psychosocial, physical, mental health, and environmental assessments to evaluate clients’ needs, strengths, and goals.
• Develop and implement individualized, client-centered care plans that prioritize safety, well-being, and quality of life.
• Continuously reassess clients’ needs and modify care plans as circumstances evolve.
• Evaluate the client’s ability to remain safely at home and recommend alternative care settings when appropriate.

Care Coordination and Advocacy

• Serve as the primary liaison between IOA, Corio clients, families, physicians, caregivers, and other service providers to coordinate services seamlessly.
• Facilitate communication across care teams to ensure consistency in client care and address any gaps or barriers.
• Coordinate and monitor in-home services, such as caregiver support, private duty aides (typically IOA), and other resources, ensuring they meet client expectations and care standards.
• Initiate and facilitate care conferences/family meetings to achieve client goals.
• Ongoing evaluation of effectiveness of services and recommendations to alternative resources to maximize achievement of care plan.
• Accompany clients to medical appointments, advocating for their needs and helping interpret medical guidance.
• Provide crisis intervention and problem-solving support as issues arise.
• Facilitate transitions of care (hospital to home, hospital to SNF, higher level of care) by coordinating all involved services, activities, and parties. - Purchase goods and services on behalf of clients to meet basic needs and deliver effortless access to needed items.
• Serve as primary point of contact for care coordination with medical, non-medical, fiduciaries, home care partners, durable power of attorneys, responsible parties, loved ones, and others.

Client and Family Support

• Act as a trusted advisor to families, offering guidance and emotional support as they navigate care decisions and complex family dynamics.
• Maintain a high level of discretion and professionalism, ensuring confidentiality for an affluent and discerning client population.
• Respond promptly to urgent client needs with a solution-driven approach.

Companioa Collaboration:

• Participate in weekly interdisciplinary team (IDT) meetings across Companioa and Home Care service lines.
• Serve as the care manager to identify gaps in care and create solutions across service lines
• Conduct comprehensive biopsychosocial assessments for Companioa participants

Documentation and Administrative Duties

• Maintain timely, accurate, and detailed records of client interactions, assessments, care plans, and all care coordination activities in progress notes.
• Collaborate with home care services, billing, human resources and administrative tasks as needed.
• Leverage Wellsky technology platform to document care management activities and track outcomes.
• Complete all monthly billing activities to ensure accurate and timely billing within IOA required timeframes.
• Adhere to NASW professional standards and code of ethics.

Professional Leadership and Development

• Serve as a mentor and ASW Supervisor to PACE or other care management team members or interns as needed, fostering best practices and professional growth. (If LCSW)
• Participate in ongoing professional development, including program leadership meetings and relevant continuing education opportunities.
• Stay current with best practices in care management, aging services, and private-pay care solutions.
• Be an Institute on Aging Advocate and Ambassador.