CAP Case Manager

Job Summary:

To provide advanced social work services for the Community Alternatives Program for Disabled Adults and Children and assistance in locating, coordinating, monitoring, and assisting in determining eligibility for social, medical, financial, and other services to meet the needs of the Community Alternative Program patients.

Core Responsibilities:

• Assessment and Evaluation
• Assess which patients need social intervention and referral
• Conducts the initial pre-screening and initial assessment of the patient and family
• Evaluates needs and resources of the patient/family and need for other community services
• Planning
• Develops social work portion of the plan of care to ensure the health, safety, and well-being of patients
• Reviews and updates the plan of care at least every twelve months or as the patient status requires
• Assists the patient/family in understanding the plan of care and making informed choices
• Utilizes appropriate community resources planning as well as initiates appropriate referrals
• Provides counseling and emotional support to strengthen patient/family support system
• Implementation and Follow-up
• Collaborates with the disciplines within the agency to ensure a comprehensive approach to patient care
• Provides continuous evaluation and monitoring of services through documentation and consultation
• Participates in appropriate interagency conferences
• Serves as a liaison between patients and provider agencies
• Performs on-going systematic patient assessment through monthly telephone calls and home visits and documents according to policy
• Evaluates and documents effectiveness of care based on observable responses of patient, recommending or instituting changes needed to attain identified patient outcomes
• Provides monthly case management for assigned patients
• Documentation
• Completes all required records per agency policy and the State CAP manual
• Documents pertinent changes in patient’s condition during contacts with patients, family, and other provider agencies
• Completes a discharge summary when CAP services are completed. This summary should review services provided, patient’s response and status at discharge
• Maintains medical record for each patient with current documentation of patient status, service changes and referrals
• Maintain Case Management documentation within the E-CAP system, review In-Home Aide documentation, review re-certifications, and supply billing for proper billing codes and compliance according to CAP guidelines
• Professional Development
• Completes requirements for continuing education per year as established by agency policies and procedures
• Completes State mandated training as required; Completes E-CAP updates as required
• With the Community Alternatives Program Director, develops and achieves professional goals and revises accordingly to reflect the dynamic nature of the unit. Evaluates the goals annually
• Completes mandatory organization education as per policy