Role and Responsibilities

TheHealthHome Care Manager willprovidecollaborative, client-centered support to Health Home Program clients using the development of person-centered goals, culturally competent care management, and professional healthcare and social service coordination. Health Home Care Managers will evaluate, manage, and integrate solutions and resources for all primary, complex chronic diseases, behavioralhealthand long-term care needs in the Health Home Program.

Essential Functions

• Actively and progressively care manage an enrolled client caseload asdeterminedby Agency guidelines. Developindividualizedplansof care with specific goals/interventions/objectives, to be revised as needed.

• Providerehabilitative and supportive counseling geared toward the restoration of clients to theiroptimumlevel of social and health functioning. This includes assisting clients and their families with the adjustment to their illness and following medical/behavioral health recommendations.

• Assistthe clients and their families with personal and environmental difficulties, which predispose them towards illness and/or interfere with obtaining maximum benefits from medical care.

• Develop long-and short-term plans, whenappropriate, including theutilizationof communitysupportswith the goal of reducing emergency room and/or in-patientutilization.

• Communicate directly with members of the care team toprovideup-to-date informationregardingthe clients care to effectively reduce duplicative services.

• Consult with the physicians, Managed Care Organizations and other members of the Care Team for the purpose of educating them on the social, emotional and environmental factors related to the clients barriers to success.

• Prepare concise,accurate,andtimelycase notes which are incorporated into the clients records.

• Complete client documentation within24-hours.

• Proficiently and accurately use multiple software systems to capture care management notes and related activities, and toprovidecorrectionswhen neededregardingdocumentation in any one of the EMRs as needed, including the Lead Health Home systems, HCRs Database, and the HCS site for USA Mental Health Assessments.

• Attend case conferences and act as a consultant to other agency personnelregardingclients psycho-social issues.

• Perform required face-to-face client encounters in conformance with Health Home and Agency guidelines, adjusting frequency and duration based on client needs.

• Schedule and maintain client visits, follow-up calls, and provider engagements utilizing effective time management skills.

• Document active/progressive care management showing multiple points of engagement with a client or collateral contacts over the course of a month.

• Timely discharge of clients no longer engaged in the Health Home Program.

• Represent Care Management on agency committees and interdisciplinary team meetings as requested, as well as operate as an ambassador for HCR Care Management out in the community.

• Network with community-based agency personnel to promote HCR and its services.

• Meet/exceed performance expectations as outlined in Care Management Expectations.

• Other duties as assigned.

  This job description reflects managements assignment of essential functions; and nothing in thishereinrestricts managements right to assign or reassign duties and responsibilities to this job at any time.

  Education Requirements

• High School diploma/GED, AssociatesorBachelors Degree inHealth and HumanServices with 1to 3years of experience working directly with persons with behavioral/mental health diagnosis, substance disorders, or linking individuals with community support resources; OR

• Bachelors Degree, with1-yearrelated experience, in any of the following: child and family studies, community mental health, counseling, education, nursing, OT, PT, psychology, recreation, recreation therapy, rehabilitation, SW, sociology, or speech and hearing; OR

• NYS Licensure and current registration as anLPN or RN with1 to 3years of experience working directly with persons with behavioral/mental health diagnosis or substance disorders.

  Qualifications and Requirements

• Communicate through speaking to give instructions and explanations to employees/clients,and through hearing to understand employee/client response and questions.

• Proficient in the use of databases and/or electronic medical records.

• Possess excellent communication skills.

• Ability to interact well withpeople of all socio-economic backgrounds in the community.

• Possessorganizationalskills and the ability to manage and prioritize multiple assignments.

  Work Environment

  The Health Home CareManager1 is primarily in an office setting and may be exposed to outdoor conditions.

  The working conditions are classified as sedentary work:

• Sedentary work - Exerting up to 10 pounds of force occasionally, and/or a negligible amount of forcefrequentlyor constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time.

  Physical Requirements

  The following is a description of the physical requirements on a daily basis forthe HealthHome Care Manager 1.While performing the duties of the job the employee is regularly expected to:

• Stand

• Sit

• Hear

• Walk

• Talk

• Stoop or kneel

• Repetitive motion

  This is not necessarily an exhaustive list of all responsibilities, duties, skills, efforts, requirements or working conditions associated with the job. While this is intended to bean accuratereflection of the current job, management reserves the right to revise the job or to require that other or different tasks be performed as assigned.

  EOE/AA Minority / Female / Disability / Veteran