POSITION OVERVIEW:

The Care Manager provides patients advocacy, outreach, education, clinical services. Skills and competencies required for the position include communication, cultural competence, training professional experiences, and education. The activities are tailored to meet the unique needs of the communities. This position includesno managerial or supervisory responsibilities.

KEY ESSENTIAL FUNCTIONS:

• Provide direct coaching, education and advocacy in linking, engaging and retaining clients in services identified in the Plan of Care.
• Escort clients to appointments and provide and gather critical information, both in the field and in the office, with the goal of health and wellness promotion and a reduction in preventable negative health or social events.
• Elicit the support of all providers involved in a client’s care and ensure maximized communication among all parties via face to face contacts, phone calls, emails, case conferences, etc.
• Conduct vigorous outreach in identifying and locating potential clients either referred through the community or by the lead Health Home.
• Provide intensive care management services to clients living with chronic illnesses and their families/support systems and advocate aggressively for clients to obtain the full range of needed services and ensures coordination of these services.
• Ensures the timely completion of internal and external required assessments (Comprehensive Assessments, HARP Eligibility Assessment, Eligibility and Appropriateness Assessment, etc).
• Ensures the timely completion of the initial Plan of Care and plan reviews based on Lead Health Home policy.
• Ensures the Plan of Care for each enrolled member includes quality SMART goals, interventions and targets.
• Completes progress notes in accordance with Health Home and departmental policies.
• Responsible for the overall chart compliance of assigned caseload members.
• Demonstrate the ability to clearly articulate, verbally and in writing, the aims and goals of the Health Home program and the process to potential clients and community members and Acacia Network staff.
• Responsible for coordinating and attending provider case conferences.
• Participate in quality improvement activities, projects and reviews.
• Complete periodic requests for narrative or quantitative data reports for program review.
• Identify new sources of potential clients and conduct outreach presentations as requested.
• Meet regularly with supervisor and attend staff meetings. Be prepared to discuss clinical and operational issues impacting performance and program operations.
• Complete and submit daily activity log in accordance with departmental policies.
• Maintain and update caseload tracking tool.
• Escort clients to entitlement offices to gain, maintain or regain eligibility; Verify client eligibility through ePaces, as requested.
• Conduct outreach in accordance with Health Home policy via phone, letter, and field work to client/collateral/provider/ support system. to engage clients or strengthen connectivity.
• Conduct home visits on a monthly basis to members on caseload as needed to provide comprehensive care management services.
• Provide Diligent and Continued Search efforts in order to regain and maintain member engagement.
• Provide member referrals to Health Navigator and Outreach team via member referral to HHSA and HHSC. 
• Attend Supervision with Clinical Supervisor and Operations Coordinator as scheduled and be prepared to discuss topics around caseload, engagement, work related concerns, barriers, trainings, etc.
• Assess and respond per agency guidelines to client complaints or grievances.
• Help maintain health and wellness and prevent secondary disease complications.
• Ensure community-follow up to engage the client in care; promotes compliance with medical appointments and encourages client self-sufficiency and empowerment.
• Coordinate schedule and appointments with Health Navigator to ensure client attendance at appointments or engage in outreach efforts.
• Organize fieldwork to maximize delivery of service to clients.
• Utilize company issued cell phone to stay in contact with members/ providers/ Health Home team on a 24 hour basis.
• Coordinate, communicate and support members within serviced boroughs.

REQUIREMENTS:

• Bachelor’s Degree in one of the following fields is required: social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services fields. 
• Two (2) years’ experience in successful community outreach/recruitment or volunteer coordination.
• Excellent public speaking and presentation skills. 
• Ability to communicate effectively orally and in writing.
• Ability to connect with others and forge strong relationships.
• Highly organized, motivated self-starter. Excellent time management skills. 
• Ability to organize and maintain detailed records; complete necessary paperwork and meet deadlines. 
• General knowledge of organization, community and/or social service resources and programs.
• Bilingual – Spanish speaking a plus.