Provides care management services to eligible individuals with chronic health conditions within the Health Home Care Management program. Assist persons in navigating the service eligibility processes, providing linkage and referrals for services and support with benefit applications. Participates in outreach activities that promote services.

Position Responsibilities

• Serves as the initial contact for all persons inquiring about services. Conducts agency intake for applicants applying for agency services.
• Assists new applicants with the New York State OPWDD eligibility process according to State requirements.
• Enrolls individuals into health home services if they qualify. Completes all enrollment paperwork and billing utilizing the appropriate database.
• Prepares eligibility application for OPWDD review. Submits eligibility applications to the DDRO. Maintains communication with DDRO eligibility office and provides follow up as requested.
• Provides guidance to individuals and families with applying for necessary benefits and entitlements.
• Provides guidance to individuals and families and linkage to necessary community supports.
• Completes Health Home Care Management program registration, discharges, and all other requirements.
• Develops alongside the person, a Plan of Care using the principles of person-centered planning that includes goals, preferences and strengths, functional needs, community supports, interventions and timeframes for improving the person’s health.
• Maintains the Plan of Care with periodic reassessment of the person’s needs, progress towards meeting their goal, and documents any changes needed.
• Assists people receiving services and families with applying for necessary benefits and entitlements.
• Provides guidance and services to people as specified in the person’s care plan, provides linkages and connections to health care services, psychiatric and counseling services and other services as needed.
• Arranges for and/or provides transportation and/or accompanies the person on individual appointments to provide advocacy.
• Completes Eligibility Assessments and Community Mental Health Assessments annually and as needed for those person’s enrolled in HARP.
• Monitors for a person’s satisfaction with support and services through contact as required based on the care plan or current situation.
• Conducts community outreach and education as assigned.
• Documents all care management activities contemporaneously.
• Facilitates, completes and maintains required individual records, including case notes, assessments, billing and any required paperwork in compliance with OPWDD, ECDMH, or the NYS Dept. of Health regulations and associated Health Home requirements in the appropriate associated database (i.e. Health Commerce System, BTQ, MEDENT, Care Manager Netsmart, Therap, etc.)
• Files and processes Incident Reports/ Events per the associated Health Home’s policies. Ensures appropriate interventions and follow-up as needed.
• Ensures compliance with the associated Health Home’s policies and procedures.

Education and Experience:

• Qualifications for Care Managers serving Low and Medium acuity enrollees are left up to the discretion of the Care Management Agency to provide flexibility to make operational decisions that best reflect the mix of children served by an individual Care Management Agency.
• New York State requires that Health Home Care Managers that serve High acuity enrollees or those part of the High-Fidelity Wraparound Pilot (when implemented) have the following minimum education:
  • Bachelor’s degree Arts or Science with 2 years of relevant experience, or
  • A valid NYS Registered Nurse license with 2 years of relevant experience, or
  • Master’s degree with one year of relevant experience.

Skills, Knowledge, and Abilities:

• Knowledge of developmental disabilities.
• Good oral and written communication skills and basic computer skills.
• Working knowledge of community-based services for the population.
• The ability to read and write case notes as well as understand written directions.
• The ability to organize, plan and manage caseload with flexibility, dependability, discretion, and independent judgment.

Certifications:

• Maintains mandated training on required assessments by NYS Dept. of Health and the associated Health Homes.

Be authorized as an Agency Driver by

• Holding and maintaining a valid NYS Driver’s License.
• Maintaining an approved driving record according to Agency Policy and Procedure.
• Have and maintain have use of personal vehicle for work purposes; travel between work locations and transporting people served.

Physical and Mental Requirements:

• Seeing, hearing, walking, sitting, standing, and driving.
• Exercising independent judgment, concentrating, thinking, communicating, interacting with others, managing multiple tasks, and coping with stressful situations and deadlines.
• Staying awake and alert while on duty.

Working Conditions:

• Will work in an office environment, typically during business hours. May need to work outside of business hours to accommodate appointments or a person’s needs.
• Frequent local travel required.

Community Services for Every1 has supported the people of our community for over 30 years. Those with intellectual and developmental disabilities, and those who are simply in need. Every day, our efforts support over 2,000 individuals of all abilities, across counties. We are here for Western New Yorkers – all of them.

Helping those in need takes very special people. And those people are the lifeblood of Community Services for Every1. They’re employees who thrive on helping and who have a passion for connecting. Who can form lifelong bonds with the people they support and make the biggest difference in the lives of fellow Western New Yorkers.

Just as we empower those we serve, we strive to empower each other. We support our colleagues through challenges and we collaborate to find the best solutions – and we work hard to help each other grow. Community Services for Every1 offers competitive starting pay based on directly related experience, generous time off, excellent benefits plans and an opportunity to grow!