Care Manager - Certified Community Behavioral Health Clinic; CCBHC

Position: Care Manager - Certified Community Behavioral Health Clinic (CCBHC)
Job Type

Full-time

Description

The CCBHC Care Manager (CM) will be employed by Central New York Health Home Network (CNYHHN) and embedded within Community Health and Behavioral Services (CHBS). This role focuses on providing Health Home expertise, including eligibility, referral processes, and related guidance to the Targeted Case Management (TCM) team at CHBS, with the goal of reconnecting existing Health Home members to services and linking new members to Health Home Care Management.

The CM will be fully integrated into the TCM team and is expected to perform all tasks associated with the TCM Case Manager position, including documentation in CHBS's electronic medical record system, Credible. Responsibilities include assisting individuals in achieving stability across all life domains by providing referrals, advocacy, accompaniment, and support in developing rehabilitative interventions and identifying resources to reduce future stressors, regardless of Health Home eligibility or connection.

Additionally, the CM will work closely with CNYHHN's Referral Department and Intake Team. At times, this position may be responsible for partially or fully completing Health Home enrollment paperwork to expedite access to Health Home Care Management services.

Requirements

Activities include but are not limited to the following:

• Coordinate care across settings and providers to ensure seamless transitions for clients across the full spectrum of health services, including acute, chronic, and behavioral health needs; (i.e. hospital, treatment facility, skilled nursing, correctional facility).
• Conduct TCM & PRS intake assessments to develop a person-centered and recovery-oriented Treatment Plan.
• Provide advocacy, translation, psychoeducation, skill development, accompaniment and linkage to care for all the services that will help clients increase personal and family stability and achieve recovery goals.
• Collaborate with all multi-disciplinary team members to maximize integration of care across all systems and programs.
• Provide comprehensive hands-on training to enhance coping skills, social skills, and daily living skills.
• Use Motivational Interviewing (MI), Screening Brief Intervention and Referral to Treatment (SBIRT) and brief counseling to address barriers to achievement of recovery and case management goals.
• Provide rapid intensive intervention to homeless individuals with a suspected or documented mental illness/substance use problem and assist them in developing and maintaining stability in their lives.
• Complete all required documentation according to program regulations.
• When applicable, review and/or create documentation, in Foothold Care Management (FCM), for Health Home related activities
• Participate in agency or community activities as part of the treatment team that may include meetings, trainings, committees and community events.
• Provide insight and information about Health Home Care Management services, eligibility, and referral process to the TCM team and any other CHBS team members.
• Engage in outreach efforts to promote awareness of CHBS services.
• Conduct proactive outreach and engagement with parents/caregivers who express interest in
• Health Home Care Management services.
• When applicable, Gather required documentation and ensure compliance with enrollment standards, including consent forms, assessments (e.g., CANS-NY, HARP), and verification of eligibility.
• Participate/Facilitate meetings between CNYHHN and CHBS staff to review shared members, increase communication between the two agencies, and troubleshoot any workflow issues that may arise.

Supervision Responsibilities

• None

Universal Responsibilities

• Comply with all pertinent regulatory and agency regulations and operating standards.
• Establish a work environment that creates positive communication between supervisors and employees and assimilates new employees to the Agency's culture, values and mission.
• Participate in activities as part of the team that may include meetings, trainings, and committees.
• Other duties as assigned.

Required Skills/Abilities

• Excellent verbal and written communication skills
• Excellent interpersonal skills.
• Excellent organizational skills…