Care Manager, HCM

Responsibilities

• Reports to assigned Care Coordination Supervisor and meets with Care Coordination Supervisor on a bi-weekly basis for supervision or as needed.
• Utilizes approved Home Health assessment tools and Health Information Technology (HIT) to prepare initial and ongoing clinical and psychosocial assessments of service needs to identified members.
• Identifies the level of need and ensures the care plan is member-centered.
• Reassessing care plans and assessments in accordance with Health Home policy and as needed.
• Maintains detailed, accurate, and timely documentation of case notes.
• Responds to inpatient and ER admission alerts and contacts medical provider/hospitals for admission/discharge information.
• Recognizes member as a contributing member of the care team through motivational interviewing techniques, continuous transference, and reinforcement of self-management skills.
• Provides support to members and family, including but not limited to locating resources to eliminate barriers and advocating on behalf of the member and their supports to ensure they have the support necessary to improve their health.
• Documents a monthly BSQ assessment for each assigned member.
• Develops resources for referral in all areas needed to assist clients.
• Safeguards the care management team will provide care coordination, appropriate linkages, referrals, and follow-up for needed services and supports.

Qualifications

• Bachelor's Degree in Human Services or related fields such as child and family studies, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreational therapy, rehabilitation, social work, sociology, or speech and hearing; OR
• A NYS Teacher’s Certificate with a Bachelor’s Degree; OR
• NYS licensure and registration as a Registered Nurse and a Bachelor’s Degree;
• At least One (1) year experience in providing direct services or linking persons to a broad range of services essential to successfully living in a community setting to persons with mental illness, substance use disorders, HIV, and homelessness.
• Willingness to travel regularly in the community and to members’ homes as needed.
• Computer literacy including proficiency in Microsoft Office Suite and EHR.
• Experience working directly with people from diverse racial, ethnic and socioeconomic backgrounds.
• Flexibility is needed as members may call outside of daily work schedule (24-hour call).
• Ability to demonstrate excellent interpersonal skills to interact effectively with staff and patients.
• Excellent oral and written communication skills.
• Team player and able to work independently.