Health Home Care Manager

Responsible for assisting in the management of care for adults with significant behavioral health needs. Facilitate the integration of physical health, mental health, and substance use services for individuals requiring specialized approaches, expertise and protocols which are not consistently found within most medical plans.

Education/Qualifications:

• A bachelor´s degree in any of the following: child & family studies, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreation therapy, rehabilitation, social work, sociology, or speech and hearing; OR NYS licensure and current registration as a Registered Nurse and a bachelor´s degree; OR A Bachelor´s level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses; OR A Credentialed Alcoholism and Substance Abuse Counselor (CASAC).
• Highly motivated, well organized, empathetic individual.
• Position continually requires demonstrated poise, tact, and diplomacy.
• Aptitude to demonstrate strong oral /written and listening skills.
• Ability to thrive in an independent, self-guided manner.
• Understanding of mental illness and co-occurring disorders, engagement strategies, wellness self-management,
• Demonstrate acceptable social skills, hygiene practice and use of prudent judgment and acceptance of a diverse society.
• Basic computer software knowledge (i.e., Word, Excel, Microsoft Outlook etc.…).
• Excellent analytical skills and attention to detail
• Valid driver’s license, acceptable driving record with auto insurance coverage as defined by agencies carrier.

Key Job Functions (include but not limited to):

• For all HARP enrolled individuals, conduct HARP/HCBS Eligibility Assessment in the Uniform Assessment System (UAS-NY) within the Health Commerce System to determine individual’s eligibility for HCBS Tier 1 and/or Tier 2 services
• Identify and review HCBS services with the individual and create an Initial Plan of Care which is inclusive of the individual’s selected HCBS services
• Send completed Initial Plan of Care to individual’s Managed Care Organization (MCO) for service approval
• Complete applicable documentation for MCO approved HCBS services and send to HCBS providers referred by the MCO
• Create a person centered Plan of Care that clearly identifies goals and timeframes for improving the individual’s health and social situation, including interventions that will produce positive outcomes
• Submit the Plan of Care utilizing the template provided by the Department of Health to the MCO and approved HCBS service providers
• Maintain contact with MCO and HCBS service providers to eliminate barriers related to access to services and to ensure quality service delivery per the individual’s HARP/HCBS Plan of Care
• Provide ongoing monitoring of the HARP/HCBS care plan and of each client’s needs, e.g., prevention, wellness, medical, specialist and behavioral health treatment, care transitions and social and community services
• Coordinate and provide access to preventive and health promotion services through the Health Home
• Network, HCBS delivery system and other community resources including prevention of mental illness and substance abuse disorders
• Build relationships with the individual and all members of the treatment team to support continuity of care and promote health

Key Job Functions (include but not limited to) - Cont.:

• Coordinate and participate in regular case review meetings that include all members of the interdisciplinary team.
• Identify available community-based resources and actively manage appropriate referrals, access, engagement, follow-up, and coordination of services.
• Ensure follow-up of tests, treatments, services and referrals incorporated into the client’s plan of care
• Accountable for engaging and retaining clients in care
• Document each client interaction comprehensively and concisely.
• Advocate for client access of entitlement programs, treatment facilities, and other needed community services.
• Promote client access into internal agency services including, but not limited to support groups, housing Services, behavioral wellness, Substance use treatment, and medical care.

Arbor Housing and Development Expectations:

• Report to work on time and work your scheduled shift, except in cases of emergency.
• In the case of an emergency, contact your immediate supervisor and/or on call designee for guidance.
• Complete, clear, quality, integrity based and timely documentation for each client on your assigned caseload.
• Effectively discharge the key job functions of your job in accordance with Supportive Services rules and regulations, AHD Code of Conduct and Standard of Acceptable Behavior
• Support a Non-Discrimination/Anti-Harassment/Sexual Harassment free work environment, foster a respectful environment and refrain from unprofessional conduct as referenced in the Personnel Policy Manual

Physical Demands / Environment

• Bending, stretching, and standing for extended periods of time
• Lift, push or pull 25 to 50 pounds.
• Client residence, remote and/or office setting at location assigned i.e., Hornell, Bath or Corning

Critical features of this job are described above. They may be subject to change at any time due to reasonable accommodation or other reasons. Management reserves the right to assign or reassign duties and responsibilities to this job at any time.