Health Home Care Manager

Scope and Purpose

The Full Time Care Manager on our Utica Corps Team provides outreach and enrollment services to individuals presumed to meet eligibility requirements of New York State’s Health Home program. They gather assessments and enter documentation that confirms eligibility and identifies areas requiring supportive services. They work with individuals and service providers to create a comprehensive Plan of Health Care, identify additional service providers as necessary, and coordinate the continuing involvement of individuals and service providers in the execution of the plan. Care Manager documents progress and arrange for eventual transition between health homes as necessary, or from health homes to other levels of service following changes in eligibility.

Essential Duties and Responsibilities

• Assesses, engages and enrolls clients into health home program, per NYSDOH and Lead Health Home
• Maintain engagement with individuals who are often disengaged from care, have difficulty adhering to treatment recommendations, or have a history of homelessness, criminal justice involvement, or high ED/Inpatient utilization
• Work within the community to engage individuals who meet Health Home Plus
• Complete face-to-face visits with enrolled members at least once/month; at a frequency determined by client need
• Collaboratively complete a yearly assessment of needs, strengths and goals with the member/family and care teams
• Facilitate yearly (minimum) meetings with members’ care teams and work within that team to develop a comprehensive Plan of Care
• Provide the following core services to enrolled members: care coordination, comprehensive care management, transitional care, crisis intervention and caregiver/family support (coordinating with care team, making referrals to other providers, ensuring follow up from hospital discharges/ED visits, ensures preventive medical/dental care, etc.)
• Document all case activities in an Electronic Health Record, following the NYS guidelines around documentation quality and time frames
• Ensure that monthly billing standards are met for each enrolled member and that a billing questionnaire is submitted within the month that the activity took place

Special Skills, Certificates, Licenses, Registrations

• Bachelor’s Degree with two years of experience; Master’s Degree with one year of experience preferred
• Relevant experience in serving children and families in child welfare, developmental disabilities, behavioral health, primary health care, or social services
• Experience coordinating and participating in team settings
• Solid writing and verbal communication
• Work effectively and knowledgeably across a broad spectrum of cultural, ethnic, and racial communities
• Ability to work in an effective and focused manner when self-directed and beyond immediate oversight
• Ability to deliver family-driven, youth-guided services
• Requires computer proficiency including word processing skills and the ability to provide culturally competent practice