Children's Health Home Care Manager

Job Title: Children’s Health Home Care Manager

Job Summary:

Care Management is a service model whereby all of an individual's caregivers communicate and interface so that the patient's needs are addressed in a comprehensive manner. This is done primarily through a "care manager" who oversees and provides access to all of the services an individual needs to assure that they receive everything necessary to prevent hospitalizations, stay healthy, and maintain stability.

The Care Manager is ultimately responsible for the overall provision and coordination of services to assigned caseload. The Care Manager guides program enrollees and their caretakers (legal guardians) through the health care system by assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes.

Primary Duties & Responsibilities include, but are not limited to:

● Obtains required Care Management enrollment consents from the individual or legal guardian.

● Completes initial and ongoing needs assessments (Child and Adolescent Needs and Strengths - NY (CANS-NY) to determine the individual’s most appropriate level of care management.

● Responsible for the overall management of the patient’s individualized Plan of Care. Through the creation of an individual Plan of Carethe Care Manager is able to:

A. Coordinate the enrollee’s provision of services as per their acuity level;

B. Support adherence to treatment recommendations; and

C. Monitor and evaluate a patient’s needs, including prevention, wellness, medical, mental health, care transitions, and social and community services where appropriate.

● Meets client contact requirements (keeping in mind that caseloads may be “blended”):

A. Care Managers serving children will be required to have face-face visits on a consistent schedule as per the mandates of their acuity level (high, medium, or low).

● Meets Care Management documentation requirements in a timely and accurate manner by effectively utilizing designated Care Management Portal (Medicaid Analytics Performance Portal (MAPP) and Electronic Health Records (EHRs) as needed.

● Functions as an advocate for clients within the agency and external service providers

● Promotes wellness and prevention by linking enrollees with resources and services based on their individual needs and preferences.

● Educates the child/caregiver on care of chronic conditions, immunization, screening and other preventive interventions.

● Helps clients to obtain and maintain public benefits necessary to gain health care services, including Medicaid, Temporary Assistance for Needy Families (TANF), Social Security, housing, legal services, employment and training supports, and others.

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

● Conducts care planning meetings/conferences and serves as an interdisciplinary team member to effectively provide/coordinate comprehensive and holistic care.

● Identifies 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 all recommended post discharge services in place prior to discharge.

● Attends and participates in ongoing staff development trainings to enhance skills needed to effectively meet the demands of the Care Manager position.

● Ensure that child has periodic evaluations and follow up treatment for dental, vision and hearing care, following Medicaid EPSDT guidelines. Any additional activities requested by the President/CEO, Deputy Executive Director, and Oversight Staff.

Education/ Qualification Criteria:

Education and/or credential requirements are determined by children’s acuity level and require one or more of the following:

● Bachelors of Arts or Science with two years’ experience.

● Registered Nurse or Licensed Practical Nurse with two years’ experience.

● A Master’s Degree in related field (License preferred).

● Bilingual is a plus.

The candidate must possess the following experience:

● A minimum of two years of relevant expertise and experience in serving children and families in child welfare, developmental disabilities, mental health, healthcare and/or other systems as well as those receiving preventive services.

● Care Managers serving high acuity enrollees will be required to have demonstrated knowledge and understanding of the needs of such children and their families as evidenced by additional years of experience, education, or training.

● Care Managers assigned to children who have medical fragility must have extensive experience in coordinating their care.

● Experience providing service coordination and information, linkages, and referrals for community-based services.

In addition the candidate must demonstrate the following Competencies:

● Excellent writing, communication, and organizational skills.

● A passion for serving children and families with special needs.

● Ability to travel to community-based agency offices, participant’s communities, and homes within assigned catchment area.

● Ability to receive feedback to professionally grow and/or improve.

● Proven self-management abilities, including meeting deadlines, ensuring compliance with agency policy and procedures, and overseeing complete and timely maintenance of agency records, in accordance with contractual requirements.