Care Managers, Long-Term Care Management

Department: AAA
FLSA Status: Non-Exempt
Job Type: Full Time


Due to severe staffing shortages brought about by dramatically increased need in the community for services, we are just not able to meet continuously increasing need and thus many needy people are wait-listed for services. We have multiple full-time positions in Elkhart, LaPorte, Marshall and St. Joseph Counties. Our Long-Term Care Managers are responsible for providing information, referrals, and options to individuals, addressing individual needs, and managing the coordination of individuals’ on-going care. The professionals in these positions promote the independence of the people we serve and seek to empower the individuals to maintain/regain their ability to care for themselves to the highest degree possible while continuing to advocate for them when needed.

ESSENTIAL DUTIES include the following. Other duties may be assigned.

  • Meet with individuals, families, and caregivers to provide a comprehensive assessment of needs and facilitate
  • Options Counseling. Identify the individual’s strengths, values, and preferences. Identify resources available to individuals and their circle of support (formal and informal supports including community organizations).
  • Screen individuals for potential eligibility for funding sources and programs. Determine eligibility for on-going home and community-based services.
  • Assist in accessing home and community-based services that would meet identified needs. Take action to initiate appropriate services. Develop an initial service plan and submit level of care documentation.
  • Update, reduce, and terminate care plans/services based on the individual’s current needs. Follow-up to ensure services are meeting the individual’s needs. Use resources wisely, ensuring services are cost-effective, appropriate, and needed.
  • Assist individual with completing Medicaid application, gathering and submitting required documents, attending application interview, and follow-up until eligibility is determined by the
  • Division of Family Resources.
  • Contact individual’s preferred vendors to secure provider.
  • Complete PASRR Level 1, Level of Care Tools, and Options Counseling, as defined by the
  • Division of Aging for long-term care management individuals.
  • Complete required documentation and reports in a concise and timely manner.
  • Coordinate workflow and coverage with other agency staff members.
  • Attend staff meetings and training sessions as scheduled.
  • Maintain care management standards and meet task timelines. Contribute actively to the outcomes of the team and meet team expectations.
  • Alert Team Leader when consultation is required. Work with Team Leader and other disciplines when additional consultation is required.
  • Contribute to an environment that supports our mission of individual service and care.
  • Abide by all agency Personnel Policies and Code of Ethics.
  • Apply person-centered care philosophy and “needs-based” service model.
  • Provide excellent customer service. Serve individuals in a manner that is empowering, encourages independence, is patient, compassionate, and person-centered.
  • Advocate on behalf of the individual’s needs.


Our Care Managers are responsible for performing interviews with inquirers and with established individuals to assess their needs, determine eligibility for programs, make recommendations for community services or alternate living arrangements, seek out resources to meet needs, determine appropriateness of services, determine level of care, and manage Action Plans and Plans of Care, all based on the needs of the individual. Care Managers are responsible for performing ongoing activities that ensure access to all services from which an individual might benefit. Additionally, Care Managers maintain ongoing case records and make recommendations for community services or alternate living arrangements based on the needs of the individual in their care. In keeping with a person-centered care model, Care Managers recognize each person’s unique needs and work with the individual’s circle of support (formal and informal supports) to meet needs.

Care Managers must be well-versed in evaluating needs based on supporting independence and empowerment and must understand the requirements of various funding sources. It is essential that work is completed in a quality and timely manner, efficiently and accurately, in accordance with program standards and guidelines. It is sometimes necessary to use some analysis and judgment in determining the best procedure to follow or how to best communicate information to caregivers and inquirers who may be in stressful situations.


Bachelor’s degree (BA or BS) from an accredited four-year college or university in social work, psychology, gerontology, counseling; or a license as a registered nurse with one year of experience in human services; or a bachelor’s degree in any other field with a minimum of two years, full-time direct services experience with the elderly or disabled persons. This experience must include assessment, plan of care development, implementation, and monitoring. Or applicant may have a master’s degree in a related field to substitute for the required experience. (Division of Aging Application for 1915 (c) HCBS Waiver: IN0201.R06.00- July 01,

  • Maintain ongoing Care Management certification.


  • Specialized knowledge of principles and practices developed through relevant experience after a baccalaureate education or nursing equivalent
  • Ability to assess an individual’s specific needs and plan solutions; to understand, empathize, and relate to the behavior of individuals; to certify initial and ongoing eligibility for programs and services being authorized on the service plan.
  • Ability to assess specific needs both in person and on telephone; ability to develop rapport quickly
  • Knowledge of options, funding sources, services, resources, and information available through REAL Services and in the community. Knowledge of in-home and community-based services, funding sources,
    and eligibility. Understands basics of Medicare, Medicaid, Private insurance, other benefits, and other payment options
  • Excellent communication skills, both orally and in writing with good interviewing skills. Ability to tactfully
    and diplomatically convey decisions to an individual and their family.
  • Ability to organize information, prioritize assignments, complete tasks in a timely manner, and to
    use sound judgment.
  • Ability and attitude to work productively independently and cooperatively and relate to the needs
    of the staff, the individual, and the agency.
  • Ability to follow instructions and procedures, to interpret information, and to complete assigned
    tasks in accurate, concise, and detailed manner.
  • Ability to operate office equipment, including but not limited to phone, facsimile, copy machines,
    and computer equipment.
  • Ability to learn State-approved software and other computer programs as relevant to successful completion of tasks. Ability to use Microsoft Word, Access, Excel. Ability to use ipad for care management assessment functions and other related tasks.


The work demands sound judgment is exercised in selecting the most tactful approach in communicating with the individual and their family. All documentation must be accurate and timely. The work is repetitive in nature inasmuch as the same tools, forms, and procedures are utilized routinely, but does involve variables and considerations when dealing with diverse situations and when preparing a care plan or considering alternatives in individual cases. Travel independently within Elkhart, Kosciusko, LaPorte, Marshall, and St. Joseph counties in Indiana is required.


  • With various individuals, their families, and caregivers
  • With community professionals and agencies
  • With providers
  • With Agency staff members


The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is usually seated, standing, or walking at will in a typical office setting. Very limited physical effort required.

  • Valid driver’s license and a dependable vehicle required.
  • Regular and reoccurring travel to meetings, training, and individual visits required.


  • Must learn any internal resource databases.
  • Must learn the State approved care management systems.
  • Successful candidate must submit to a pre-employment drug screening and a limited criminal history check.
  • Proof of educational credentials is required at time of employment.
  • This position has a 6 month probationary period.
  • Must sign non-compete clause.


  • Health insurance
  • Flexible Spending Account
  • Dental insurance
  • Vision insurance
  • Life and disability insurance
  • Two-part retirement plan
  • Paid vacation
  • Paid personal days
  • Paid sick leave
  • After six months, eligible for Flexible work schedule within 4 or 5 day work week
  • 8 1/2 paid holidays
  • Plus a bonus paid floating holiday that you choose
  • 37.5 hours/week
  • Mileage reimbursement
  • iPad and other necessary tech equipment will be provided for home office use

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