Health Home Care Manager

Steuben Churchpeople Against Arbor Housing & Dev•Corning, NY

About The Position

The Health Home Care Manager assists in managing care for adults with significant behavioral health needs. The role facilitates the integration of physical health, mental health, and substance use services for individuals who need specialized approaches, expertise, and protocols. The Care Manager coordinates person-centered care plans and services, works with clients and interdisciplinary treatment teams, and helps clients access health, behavioral health, HCBS, and community resources. The position may be based in a client residence, remotely, and/or in an assigned office location in Hornell, Bath, or Corning.

Requirements

A bachelor’s degree in child and family studies, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreation therapy, rehabilitation, social work, sociology, or speech and hearing; or
NYS licensure and current registration as a Registered Nurse and a bachelor’s degree; or
A bachelor’s-level education or higher in any field and five years of experience working directly with people with behavioral health diagnoses; or
Credentialed Alcoholism and Substance Abuse Counselor (CASAC).
Highly motivated, well organized, and empathetic.
Demonstrated poise, tact, and diplomacy.
Strong oral, written, and listening skills.
Ability to work independently and in a self-guided manner.
Understanding of mental illness, co-occurring disorders, engagement strategies, and wellness self-management.
Acceptable social skills and hygiene practices, prudent judgment, and acceptance of a diverse society.
Basic computer software knowledge, including Word, Excel, and Microsoft Outlook.
Excellent analytical skills and attention to detail.
Valid driver’s license, acceptable driving record, and auto insurance coverage as defined by the agency’s carrier.

Responsibilities

Conduct HARP/HCBS Eligibility Assessments in the Uniform Assessment System (UAS-NY) through the Health Commerce System for HARP-enrolled individuals.
Review HCBS services with individuals and create an Initial Plan of Care that includes their selected HCBS services.
Send Initial Plans of Care to individuals’ Managed Care Organizations (MCOs) for service approval.
Complete documentation for MCO-approved HCBS services and send it to HCBS providers referred by the MCO.
Create person-centered Plans of Care with goals, timeframes, and interventions intended to improve clients’ health and social situations.
Submit Plans of Care using the Department of Health template to MCOs and approved HCBS service providers.
Maintain contact with MCOs and HCBS providers to address service access barriers and support quality service delivery in accordance with each individual’s plan.
Monitor HARP/HCBS care plans and client needs, including prevention, wellness, medical and specialist care, behavioral health treatment, care transitions, and social and community services.
Coordinate access to preventive and health promotion services through the Health Home Network, HCBS delivery system, and other community resources, including resources for preventing mental illness and substance use disorders.
Build relationships with individuals and treatment-team members to support continuity of care and promote health.
Coordinate and participate in regular case review meetings with interdisciplinary team members.
Identify community-based resources and manage referrals, access, engagement, follow-up, and service coordination.
Ensure follow-up on tests, treatments, services, and referrals included in clients’ Plans of Care.
Engage clients and support their retention in care.
Document each client interaction comprehensively, concisely, clearly, and in a timely manner.
Advocate for clients’ access to entitlement programs, treatment facilities, and other needed community services.
Promote access to agency services, including support groups, housing services, behavioral wellness, substance use treatment, and medical care.
Work scheduled shifts and contact the immediate supervisor or on-call designee for guidance in an emergency.
Perform job functions in accordance with Supportive Services rules and regulations, the AHD Code of Conduct, and the Standard of Acceptable Behavior.
Support a non-discriminatory, harassment-free, and respectful work environment and refrain from unprofessional conduct.