Children's Health Home Care Manager

Position Type / Expected Hours

40 hours weekly. Flexible to the needs of the program.

Qualifications

• Bachelor’s degree with two (2) years relevant experience, or NYS licensure and registration as a Registered Nurse, or a Master’s degree with one (1) year relevant experience.
• Strong written, verbal, and organizational skills.
• Computer skills necessary.
• Travel within the tri‑county area frequently.
• Authorized to work in the United States.

Summary / Objective

The Care Manager conducts and schedules assessments, referrals, advocacy and supports, counseling, and education of patients, enrollees, and care team members, assuring the patient receives quality services to maintain optimum healthcare needs without barriers. Performs outreach and engagement to formally enroll referred individuals into the care management program, conducts assessments, evaluates needs, establishes and maintains care plans, and maintains referrals for enrollees. Ensures supports are in place, including peer and family contacts.

Essential Functions

• Develops an Interim Plan of Care based on preliminary clinical information and assigned level, identifying immediate linkages and services required.
• Ensures all initial linkages are established and maintained.
• Collaborates with all service providers and establishes a team communication plan.
• Monitors goals on a continuing basis and ensures team communication.
• Ensures the care plan aligns with health‑home policies and procedures.
• Consults with family members and social supports to maintain support consistency.
• Advocates for additional services and linkages as appropriate.
• Maintains current care‑management documentation and information within the required health information technology (HIT) system.
• Enters and maintains progress notes related to the Plan of Care.
• Attends quarterly regional meetings for the Central New York Health Home Network (CNYHHN).
• Participates in monthly conference calls with CNYHHN providers.
• Engages families in the outreach process once a referral is received.
• Ensures compliance with CNYHHN policies and procedures.
• Attends all required online and in‑person training mandated by CNYHHN and the agency.
• Participates with agency committee(s) as assigned.
• Completes all required in‑services.
• Provides rotating after‑hours on‑call coverage outside regular working hours, with additional compensation per organizational policy.

Competencies

• Ethical Conduct
• Time Management
• Organization Skills
• Project Management
• Personal Effectiveness / Credibility

Work Environment

This role operates in a professional office environment and routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines.

Physical Demands

The employee is regularly required to talk or hear, frequently required to stand, walk, lift, use hands to finger, handle or feel, and reach with hands and arms.

Other Duties

This job description is not designed to cover all activities, duties, or responsibilities that may be required. Duties, responsibilities, and activities may change at any time with or without notice.