Prime Care Coordination
  • Buffalo, NY, USA
  • Full Time


The Care Manager's primary function is to work in partnership with individuals with I/DD to coordinate care and services needed to assist individuals achieve optimal health, wellness, and life goals. The Care Manager is responsible to provide Health Home core services including comprehensive care management, care coordination and health promotion, comprehensive transitional care, individual and family support, referral to community and social support services, and use of Health Information Technology to link services. Care Managers will provide all services with a person-centered approach and that aligns with NYS OPWDD Valued Outcomes.

Essential Job Functions:

  • Conduct comprehensive assessments to identify an individual's clinical and psychosocial needs, choices, and preferences for services
  • Assess and address health and safety issues as well as barriers to care and treatment including social determinants of health
  • Collaborate with interdisciplinary team and incorporate input into comprehensive assessment and Life Plan
  • Develop and maintain a person-centered Life Plan that coordinates and integrates an individual's clinical and non-clinical healthcare related needs and services
  • Monitor and facilitate implementation of and provide updates as needed to the Life Plan
  • Incorporate health promotion and support opportunities for individuals to achieve and maintain optimal health and wellbeing
  • Coordinate and ensure access to chronic disease management
  • Facilitate referrals to clinical and community resources, including planning, referrals, and follow-up for transitional care
  • Coordinate and provide access to long-term care supports and services
  • Engage families and natural supports into the care coordination process
  • Ensure all individuals and families receive services that are culturally and linguistically appropriate
  • Advocate on behalf of the individual
  • Promote self-advocacy and the ability to self-direct
  • Use Health Information Technology for documentation, to link services, and facilitate communication among care coordination team
  • Secure all health records and other protected information with the highest regard to confidentiality and HIPAA laws and regulations
  • Maintain compliance with all state and federal laws and regulations, Medicaid compliance, and Agency policies and procedures
  • Document all services and maintain appropriate records following all established documentation procedures
  • Participate in opportunities for continued training and education
  • Perform all other duties relevant to the position as requested.
Full Job Description
Prime Care Coordination
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