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About the Role

The Health Home Care Manager will provide collaborative, client-centered support to Health Home Program clients, focusing on person-centered goals, culturally competent care management, and professional healthcare and social service coordination. This role involves evaluating, managing, and integrating solutions for primary, chronic, behavioral health, and long-term care needs within the Health Home Program.

Responsibilities

Actively manage an enrolled client caseload according to agency guidelines.
Develop and revise individualized plans of care with specific goals, interventions, and objectives.
Provide rehabilitative and supportive counseling to help clients adjust to illness and follow medical/behavioral health recommendations.
Assist clients and families with personal and environmental difficulties that may affect health and treatment.
Develop long- and short-term plans utilizing community supports to reduce emergency room and inpatient utilization.
Communicate with the care team to provide updates and reduce duplicative services.
Consult with physicians, Managed Care Organizations, and the Care Team to educate them on client-specific psycho-social barriers.
Prepare concise, accurate, and timely case notes for client records.
Complete client documentation within 24 hours.
Utilize multiple software systems for care management notes and activities, including EMRs, Lead Health Home systems, HCR’s Database, and the HCS site for USA Mental Health Assessments.
Attend case conferences and consult with agency personnel on client psycho-social issues.
Perform required face-to-face client encounters based on client needs and agency guidelines.
Schedule and maintain client visits, follow-up calls, and provider engagements using effective time management.
Document active/progressive care management with multiple client or collateral contact points per month.
Discharge clients no longer engaged in the Health Home Program in a timely manner.
Represent Care Management on agency committees and interdisciplinary team meetings.
Act as an ambassador for HCR Care Management in the community.
Network with community-based agencies to promote HCR and its services.
Meet or exceed performance expectations outlined in “Care Management Expectations.”
Perform other duties as assigned.

Requirements

Ability to communicate through speaking and hearing.
Proficient in the use of databases and/or electronic medical records.
Excellent communication skills.
Ability to interact well with people of all socio-economic backgrounds.
Organizational skills and ability to manage and prioritize multiple assignments.

Skills

Care management
Client-centered support
Person-centered goal development
Culturally competent care management
Healthcare coordination
Social service coordination
Behavioral health needs management
Long-term care needs management
Rehabilitative counseling
Supportive counseling
Community resource utilization
Interdisciplinary communication
Documentation
Time management
Networking

Location

Office setting

Work Type

Sedentary work

Experience Level

1 to 3 years of experience
1-year related experience

Education Level

High School diploma/GED
Associate’s Degree
Bachelor’s Degree in Health and Human Services
Bachelor’s Degree in child and family studies
Bachelor’s Degree in community mental health
Bachelor’s Degree in counseling
Bachelor’s Degree in education
Bachelor’s Degree in nursing
Bachelor’s Degree in OT
Bachelor’s Degree in PT
Bachelor’s Degree in psychology
Bachelor’s Degree in recreation
Bachelor’s Degree in recreation therapy
Bachelor’s Degree in rehabilitation
Bachelor’s Degree in SW
Bachelor’s Degree in sociology
Bachelor’s Degree in speech and hearing
NYS Licensure and current registration as an LPN
NYS Licensure and current registration as an RN

Equal Opportunity

EOE/AA Minority / Female / Disability / Veteran