Tailored Care Management

GENERAL POSITION DESCRIPTION: Tailored Care management is provider-based, performed at the site of care, in the home, or the community, through face-to-face interaction between beneficiaries, providers, and care managers.

Provider-based care management will promote whole-person care, foster high-functioning integrated care teams, and drive toward better health outcomes.

The model will require provider organizations to coordinate physical health, behavioral health, and IDD /traumatic brain injury (TBI) services.

Since not every duty associated with this position may be described herein, employees may be required to perform duties not specifically spelled out in the job description, but which may be reasonably considered incidental in the performing of their duties.

ESSENTIAL FUNCTIONS: The following reflects managements definition of essential functions; performance expectations and competencies for this job but does not restrict the tasks that may be assigned.

Management may assign or reassign duties and responsibilities to this job at any time due to reasonable accommodation or other reasons.

To perform this job successfully, an individual must be able to satisfactorily perform each of the duties and responsibilities outlined below.

The requirements listed below are representative of the knowledge, skill, and/or ability required.

Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions Through Tailored CM, Behavioral Health Tailored Plan beneficiaries will have a single designated care manager supported by a multidisciplinary care team to provide whole-person care management that addresses all of their needs, spanning: physical health, behavioral health, traumatic brain injuries (TBI), pharmacy, long-term services and supports (LTSS) and unmet health-related resource needs.

Tailored Care Management will: The primary responsibilities of the Behavioral Health Care Manager are to promote the whole person, and integrated care by planning, coordinating, tracking, closing gaps in care, and monitoring care to individuals to achieve the key goals of the behavioral health tailored plans.

Be available throughout the entire duration of a beneficiarys enrollment in a Behavioral Health Tailored Plan.

Be based in provider settings to the maximum extent possible, supporting integrated care and collaboration; Prioritize frequent in-person interactions between community-based care managers and beneficiaries.

Place additional emphasis on outcomes and population health management.

Effective, integrated and well-coordinated care management depends on care team members having the ability to efficiently exchange member health information and use that information to monitor and respond to medical and nonmedical issues that could affect beneficiaries.

Makes appropriate referrals to community resources and empowers individuals to be responsible for their own healthcare and personal needs.

Referrals will focus on ...