Role and Responsibilities

　　The Health Home Care Manager will p rovide collaborative, 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, behavioral health and long-term care needs in the Health Home Program.

　　Essential Functions

　　Actively and progressively care manage an enrolled client caseload as determined by Agency guidelines . Develop individualized plan s of care with specific goals/interventions/objectives, to be revised as needed.

　　Provide rehabilitative and supportive counseling geared toward the restoration of clients to their optimum level of social and health functioning . This includes assisting clients and their families with the adjustment to their illness and following medical/behavioral health recommendations.

　　Assist the 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, when appropriate , including the utilization of community supports with the goal of reducing emergency room and/or in-patient utilization .

　　Communicate directly with members of the care team to provide up - to - date information regarding the client’s 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 client’s barriers to success.

　　Prepare concise, accurate , and timely case notes which are incorporated into the client’s records.

　　Complete client documentation within 24 - hours .

　　Proficiently and accurately use multiple software systems to capture care management notes and related activities, and to provide correction s when needed regarding documentation in any one of the EMRs as needed, including the Lead Health Home systems, HCR’s Database , and the HCS site for USA Mental Health Assessments.

　　Attend case conferences and act as a consultant to other agency personnel regarding client’s 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 management’s assignment of essential functions; and nothing in this herein restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

　　Education Requirements

　　High School diploma/GED, Associate ’ s or Bachelor’s Degree in Health and Human Services with 1 to 3 years of experience working directly with persons with behavioral/mental health diagnosis, substance disorders, or linking individuals with community support resources ; OR

　　Bachelor’s Degree, with 1 - year related 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 a n LPN or RN with 1 to 3 years 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.

　　A bility to interact well with people of all socio-economic backgrounds in the community.

　　Possess organization al skills and the ability to manage and prioritize multiple assignments.

　　Work Environment

　　The Health Home Care Manager 1 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 force frequently or 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 for the Health Home 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 be an accurate reflection 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