Role and Responsibilities

Provide collaborative, 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, behavioral health and long-term care needs in the Health Home Program.

Essential Functions

• Actively and progressively care manage an enrolled client caseload as determined by Agency guidelines. Develop an individualized plan of care with specific goals/interventions/objectives, to be revised as needed.
• Provide rehabilitative and supportive counseling geared toward the restoration of clients to their optimum level of social and health functioning. This includes assisting clients and their families with the adjustment to their illness and following medical/behavioral health recommendations.
• Assist the 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 the utilization of community supports with the goal of reducing emergency room and/or in-patient utilization.
• Communicate directly with members of the care team to provide up-to-date information regarding the 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, and timely case 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 to provide corrections when needed regarding documentation 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 personnel regarding client’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 and maintain client visits, follow-up calls, and provider engagements utilizing effective 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. 

Education Requirements

• Associate’s or Bachelor’s Degree in Health and Human Services with 1 to 3 years of experience working directly with persons with behavioral/mental health diagnosis, substance disorders, or linking individuals with community support resources; OR
• Bachelor’s Degree, with 1 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 an LPN or RN with 1 to 3 years of experience working directly with persons with behavioral/mental health diagnosis or substance disorders.

Qualifications and Requirements

• Communicate through speaking to give instructions and explanations to employees/clients, and through hearing to understand employee/client response and questions.
• Proficient in the use of databases and/or electronic medical records.
• Possess excellent communication skills.

• Ability to interact well with people of all socio-economic backgrounds in the community.
• Possess organizational skills and the ability to manage and prioritize multiple assignments.