Provides care management services to eligible individuals with chronic health conditions within the health home care management program.

POSITION RESPONSIBILITIES

• 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 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, 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