Position: Care Manager, Critical Time Intervention (CTI)
Function: Serves as a member of the CTI Team, providing time-limited intensive care coordination for a caseload of high-risk clients. Responsibilities include the development of a person-centered care plan, providing linkage to resources, and engaging individuals in skill building.
Reports to: Team Leader, Critical Time Intervention
Location: Manhattan
Schedule: Mondays-Fridays (9:00am-5:00pm)
Tasks:
- Responsible for engaging clients at hospital bedside to provide program overview and conduct intake assessments.
- Develops rapport with clients in order to engage them in improving their health and wellness.
- Participates in weekly team meetings to discuss new referrals and provide updates on enrolled clients.
- Administers standardized health and psychosocial risk screenings according to CTI protocols and timeframes.
- Utilizes screenings to identify client needs and barriers to aid in the development a comprehensive care plan.
- Works in collaboration with the client and members of the inpatient and outpatient care team to identify and prioritize client’s healthcare and psychosocial goals.
- Responsible for overall management of client’s care plan, including coordinating all aspects of care, and supporting adherence to care plan goals, including medications and other treatments; and documenting care plan progress toward goals.
- Identifies, facilitates and secures access to needed healthcare, social services benefits, and community resources. Works in collaboration with other care team members and care providers, including behavioral health, disease care management, home care, social work and community-based organizations, to help client achieve optimal health outcomes.
- Provides comprehensive transitional care following hospitalization events in accordance with Critical Time Intervention (CTI) Protocols.
- Facilitates care delivery by scheduling appointments, obtaining necessary information, and arranging transportation.
- Embraces the team model by collaborating with members of the team and providing support as needed.
- Utilizes evidenced based practices, such as motivational interviewing, to empower clients to grow and attain goals.
- Works with family members and other collaterals of the client’s choice to facilitate planning or delivery of care.
- Implements tasks outlined on the care plan and ensures follow up and continuity of care between client interactions.
- Documents all interventions and attempted contacts in the EHR in accordance with program standards.
- Assesses domiciled client’s living conditions by conducting home visits.
- Attends in-service training as requested.
- Duties as assigned by supervisor.
PI271609782
