I. SPECIFIC RESPONSIBILITIES

· Engage referrals within 24 hours of receipt.

· Maintain 15+ client caseload or as determined by DOH.

· Complete initial and ongoing needs assessments such as the Comprehensive Assessment and NYS Eligibility Assessment for HARP.

· Responsible for the development and overall management of the Plan of Care (POC). Through the development of the POC the Care Manager is able to:

o Coordinate the member’s provision of services, including providing Care Coordination Services as identified in the five core services based on the member’s acuity level.

o Support adherence to treatment recommendations and assist/facilitate with referrals, while ensuring follow-through of these referrals.

o Monitor and evaluate a member’s needs, including but not limited to: 1. Prevention 2. Wellness 3. Medical 4. Mental Health 5. Care Transitions, and 6. Social and Community Services where appropriate.

· Meet the standard billing requirement.

· Provide the four required contacts per month; two of which are face-to-face.

· Ensures documentation is completed in a timely and accurate manner by effectively utilizing the daily activity log, and electronic health record.

· Function as an advocate for members within the agency and external service providers.

· Promote wellness and prevention by linking members with resources and services based on their individual needs and preferences.

· Educate the member/caregiver on Chronic Conditions, Immunizations, Screenings and other preventative interventions.

· Assists the member to obtain and maintain public benefits necessary to gain health care services, including but not limited to: 1. Medicaid 2. Cash Assistance Eligibility 3. Social Security 4. Supplemental Nutrition Assistance Program 5. Housing 6. Legal Services 7. Employment and, 8. Training Supports.

· Effectively communicates and shares information with the individual and their families and other caregiver with appropriate consideration for language, literacy, and cultural preferences.

· Conducts care planning meeting/conferences and services and an interdisciplinary team member to effectively provide/coordinate comprehensive and holistic care.

· Identified available community-based resources and actively manages appropriate referrals, access, engagement, follow-up and coordination of services.

· In the event of hospital admissions, actively engages in the discharge planning process ensuring that the patient has recommended post discharge services in place prior to scheduled discharge.

· Attend and participate in ongoing staff development training to enhance skills needed to effectively meet the demands of the Care Manager position.

· Ensure all members enrolled have annual/periodic evaluations and follow-up treatment for: 1. Dental 2. Vision and 3. Hearing Care as per the Medicaid EPSDT guidelines.

· Perform all other duties as assigned.

II. RELATIONSHIP WITH OTHERS & IN THE WORKPLACE

· Demonstrates professionalism at all times.

· Maintain workplace boundaries

· Promote a productive and positive work atmosphere

· Uphold agency/program vision and mission as it relates to interaction with colleagues and the families served

· Adhere to agency Code of Conduct.

In addition, employees need to possess the following characteristics:

· Be a Strong team player.

· Possess excellent communication and leadership skills.

· Work well with others and feel comfortable providing direction and guidance to subordinates.

· Evidence of the ability to practice a high level of confidentiality.

· Develop a trusting and supportive relationship with subordinates.

· Have a strong sensitivity to cultural differences presented among staff and clients within the agency.

· Possess a strong belief in people’s ability to grow and change; forge a mutually respectful partnership with persons served and their families.

· Demonstrates excellent crisis intervention skills and have the ability to remain calm while handling crisis situations.

· Ability to set limits and maintain helping role of practitioner and to intervene appropriately.

III. WORKING CONDITIONS

This is an office/field-based position, which includes regular travel within Suffolk and Nassau Counties, as well as the 5 boroughs of NYC. All office days, staff meetings and supervisory meetings are in-person and held at one of our two locations (Brooklyn/Dix Hills).

Must reside in New York.

IV. QUALIFICATIONS

· Bilingual Preferred.

· Health Home Care Managers that serve adults with Health Home Plus status must have:

a) A Bachelor’s degree in Health and Human Services, OR

b) A Bachelor’s level education or higher in an field with five years of experience working directly with persons with behavioral health diagnoses, OR

c) Credentialed Alcoholism and Substance Abuse Counselor (CASAC), OR

d) A Masters with one year of relevant experience.

· Expertise and experience in servicing youth, adults and families in child welfare, developmental disabilities, mental health, healthcare and/or other system as well as those receiving preventive services.

· Passion and knowledge for advocating on behalf of staff, children, adults and families.