Health Home Care Manager

The Health Home  Care Manager willprovidecollaborative, client-centered support to Health Home Program clients using the development of person-centered goals, culturally competent care management, and professional healthcare and social service coordination. Health Home Care Managers will evaluate, manage, and integrate solutions and resources for all primary, complex chronic diseases, behavioralhealthand long-term care needs in the Health Home Program.

• Actively and progressively care manage an enrolled client caseload asdeterminedby Agency guidelines. Developindividualizedplansof care with specific goals/interventions/objectives, to be revised as needed.
• Providerehabilitative and supportive counseling geared toward the restoration of clients to theiroptimumlevel of social and health functioning. This includes assisting clients and their families with the adjustment to their illness and following medical/behavioral health recommendations.
• Assistthe clients and their families with personal and environmental difficulties, which predispose them towards illness and/or interfere with obtaining maximum benefits from medical care.
• Develop long-and short-term plans, when appropriate, including theutilizationof communitysupportswith the goal of reducing emergency room and/or in-patientutilization.
• Communicate directly with members of the care team toprovideup-to-date informationregardingthe client’s care to effectively reduce duplicative services.
• Consult with the physicians, Managed Care Organizations and other members of the Care Team for the purpose of educating them on the social, emotional and environmental factors related to the client’s barriers to success.
• Prepare concise,accurate,andtimelycase notes which are incorporated into the client’s records.
• Complete client documentation within
  24-hours.
• Proficiently and accurately use multiple software systems to capture care management notes and related activities, and toprovidecorrectionswhen neededregardingdocumentation in any one of the EMRs as needed, including the Lead Health Home systems, HCR’s Database, and the HCS site for USA Mental Health Assessments.
• Attend case conferences and act as a consultant to other agency personnelregardingclient’s psycho-social issues.
• Perform required face-to-face client encounters in conformance with Health Home and Agency guidelines, adjusting frequency and duration based on client needs.
• Schedule andmaintainclient visits, follow-up calls, and provider engagementsutilizingeffective time management skills.
• Document active/progressive care management showing multiple points of engagement with a client or collateral contacts over the course of a month.
• Timely discharge of clients no longer engaged in the Health Home Program.
• Represent Care Management on agency committees and interdisciplinary team meetings as requested, as well as operate as an ambassador for HCR Care Management out in the community.
• Network with community-based agency personnel to promote HCR and its services.
• Meet/exceed performance expectations as outlined in “Care Management Expectations.”
• Other duties as assigned.

This job description reflects management’s assignment of essential functions; and nothing in thishereinrestricts management’s right to assign or reassign duties and responsibilities to this job at any time.

• High School diploma/GED, Associate’sor Bachelor’s Degree in Health and Human Services with 1to 3years of experience working directly with persons with behavioral/mental health diagnosis, substance disorders, or linking individuals with community support resources;
  
  OR
• Bachelor’s Degree, with1-year related experience, in any of the following: child and family studies, community mental health, counseling, education, nursing, OT, PT, psychology, recreation, recreation therapy, rehabilitation, SW, sociology, or speech and hearing;
  
  OR
• NYS Licensure and current registration as anLPN or RN with1 to 3years of experience working directly with persons with behavioral/mental health diagnosis or substance disorders.

• Communicate through speaking to give instructions and explanations to…