Health Home Care Manager I - Clinton County

HCR Home Care•Plattsburgh, NY

13h•$21 - $28

About The Position

The Health Home Care Manager provides collaborative, client-centered support to Health Home Program clients through person-centered goal development, culturally competent care management, and coordination of healthcare and social services. The role evaluates, manages, and integrates solutions and resources for clients’ primary, complex chronic disease, behavioral health, and long-term care needs. The position manages an assigned client caseload, develops and updates individualized plans of care, offers rehabilitative and supportive counseling, and helps clients and families address personal and environmental barriers to health and care. The Care Manager coordinates with physicians, Managed Care Organizations, care teams, community organizations, and agency personnel; documents client services and outcomes; and completes required face-to-face encounters and follow-up. The role is primarily based in an office setting and may involve exposure to outdoor conditions.

Requirements

One of the following education and experience pathways is required: High School diploma/GED, Associate’s degree, or Bachelor’s degree in Health and Human Services, plus 1 to 3 years of experience working directly with people with behavioral or mental health diagnoses or substance disorders, or linking individuals with community support resources; OR a Bachelor’s degree with 1 year of related experience in child and family studies, community mental health, counseling, education, nursing, OT, PT, psychology, recreation, recreation therapy, rehabilitation, social work, sociology, or speech and hearing; OR NYS licensure and current registration as an LPN or RN, plus 1 to 3 years of experience working directly with people with behavioral or mental health diagnoses or substance disorders.
Ability to communicate verbally to provide instructions and explanations to employees and clients, and to hear and understand their responses and questions.
Proficiency using databases and/or electronic medical records.
Excellent communication skills.
Ability to interact effectively with people from all socioeconomic backgrounds in the community.
Organizational skills and ability to manage and prioritize multiple assignments.

Responsibilities

Actively and progressively care manage an enrolled client caseload in accordance with Agency guidelines.
Develop individualized plans of care with specific goals, interventions, and objectives, revising them as needed.
Provide rehabilitative and supportive counseling to help restore clients to their optimum level of social and health functioning, including assisting clients and families with illness adjustment and adherence to medical and behavioral health recommendations.
Assist clients and families with personal and environmental difficulties that may predispose them to illness or interfere with obtaining maximum benefits from medical care.
Develop long- and short-term plans, when appropriate, using community supports to help reduce emergency room and inpatient utilization.
Communicate directly with care team members about current client care to help reduce duplicative services.
Consult with physicians, Managed Care Organizations, and other care team members about social, emotional, and environmental factors affecting clients’ success.
Prepare concise, accurate, and timely case notes for client records and complete documentation within 24 hours.
Use multiple software systems to record care management notes and related activities, and make documentation corrections in EMRs as needed, including Lead Health Home systems, HCR’s Database, and the HCS site for USA Mental Health Assessments.
Attend case conferences and consult with agency personnel regarding clients’ psychosocial issues.
Perform required face-to-face client encounters according to Health Home and Agency guidelines, adjusting frequency and duration to client needs.
Schedule and maintain client visits, follow-up calls, and provider engagements using effective time management.
Document active and progressive care management, showing multiple points of engagement with clients or collateral contacts over the course of a month.
Timely discharge clients who are no longer engaged in the Health Home Program.
Represent Care Management on agency committees and interdisciplinary team meetings as requested, and serve as an ambassador for HCR Care Management in the community.
Network with community-based agency personnel to promote HCR and its services.
Meet or exceed performance expectations outlined in “Care Management Expectations.”
Perform other duties as assigned.