Health Home Plus Care Manager

Lakeview Health Services Inc.•Geneva, NY

16h•Onsite

About The Position

Lakeview Health Services is a premier partner throughout the Finger Lakes region, providing safe, affordable housing, support, and rehabilitative services to persons with mental illness as well as health care coordination services to individuals with chronic mental and physical health challenges. We are dedicated to helping individuals identify and achieve personally meaningful and measurable life goals, and to realize their full potential. Lakeview seeks to create an environment of learning and development that will lead to an engaged, motivated, and high performing team with a devotion and commitment to client service. With general supervision of the Care Management Program Manager, the Health Home Plus Care Manager works from a trauma informed care perspective to provide intensive support, advocacy, linkage, and coordination of services in a care management program for persons with mental illness and/or chronic health conditions, who qualify for Health Home services as designated by the Department of Health, specifically high need SMI individuals. The individual should strive to create a healing environment that respects the perspectives and experiences of the individuals, families, staff and communities we serve by practicing safe, respectful communication as well as respecting individuals’ boundaries and differences.

Requirements

A Master’s degree in one of the qualifying fields and one (1) year of Experience
A Bachelor’s degree in one of the qualifying fields and two (2) years of Experience
A Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and two (2) years of Experience
A Bachelor’s degree or higher in ANY field with either: three (3) years of Experience, or two (2) years of experience as a Health Home care manager serving the SMI or SED population
Staff who meet the Waiver qualifications as outlined by the state
NYS Driver’s License (as driving is an essential function of this position)
Qualifying fields for degrees include a major or concentration in: social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field.
Required experience must consist of: Providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse, and/or children with SED
Required experience must consist of: Linking individuals with Serious Mental Illness, children with SED, developmental disabilities, and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services).
Thorough knowledge of community services within service area
General knowledge and understanding of Mental Illnesses, Psychiatric Rehabilitation model and related issues
Basic understanding of the importance of working from a trauma sensitive perspective
General knowledge of chronic health issues and the impact they have on overall well-being
Understanding of and ability to utilize motivational interviewing
Ability to incorporate key skills to practice and engage high-need SMI individuals which can include; motivational interviewing, suicide prevention, risk screening, trauma informed care, person centered care planning and interventions, and recovery oriented approaches
Proficient in the ability to improve quality of life and outcomes for high-need individuals with SMI
Use of contemporary office equipment particularly a computer with word processing, database and report generating software
Ability to communicate effectively with diverse individuals and to record notes as needed
Ability to listen, understand and appreciate the experiences of clients
Ability to establish rapport and meaningful professional relationships
Ability to manage and resolve conflicts
Ability to provide positive role-modeling
Ability to inspire respect, confidence and trust in consumers and co-workers
Ability to respect and maintain appropriate confidentialities
Ability to effectively encourage clients toward greater independence and self-sufficiency
Ability to perceive and describe changes in behavior
Ability to generate and maintain accurate records and reports as required
Ability to seek, accept, and learn from supervisor and peer feedback
Ability to organize time effectively
Ability to plan and implement strategies consistent with consumer needs and overall organization goals, objectives, and standards
Ability to meet deadlines regularly
Ability to effectively manage change

Responsibilities

Maintain engagement with individuals who are often disengaged from care, have difficulty adhering to treatment recommendation, or have a history of homelessness, criminal justice involvement, first episode psychosis, and transitional-aged youth
Effectively support individuals through skills and practices including but not limited to motivational interviewing suicide prevention, risk screening, trauma-informed care and person-centered planning.
Hold a caseload of up to 20 individuals who meet HH+ eligibility for high need services
Ensure documentation is accurate and completed on time
Responsible for, but not limited to comprehensive assessment, outreach and engagement, service and treatment linkages and coordination using evidence-based practices and outcomes
Conduct appropriate screening and either performing or arranging for more detailed assessments when needed (e.g., high-risk substance use or mental health related indicators, harm to self/others, abuse/neglect and domestic violence)
Demonstrate proficiency at navigating the health care system, including ability to make referrals to housing services, crisis intervention, peer support.
Support consumers using trauma informed practices with linkages to identified resources, coordination of care among providers, advocacy, and support with identified recovery goals.
Develop and revise individual plans of care consistent with Health Home requirements and coordinating with the Managed Care organizations for HARP members.
Develop and maintain professional relationships through open communication and strong collaboration with community services
Personally assist consumers with identifying and achieving person centered goals and recovery
Monitor consumer wellness and ensure well-coordinated care among all providers
Develop and maintain appropriate and accurate records and files according to all county and organization policies and procedures as well as all governing and regulatory standards
Attend necessary meetings
Maintain regular and effective communications with supervisor, county service providers, and all relevant parties as needed
Collaborate with hospital or treatment providing staff as well as Managed Care Organizations for successful transitions of care
Address the quality, adequacy, and continuity of services to ensure appropriate support for individuals mental health and psychosocial health needs
Meet weekly to bi-weekly for supervision, participate in monthly clinical supervision, case conferences, and other relevant meetings and trainings
Participate in On-call rotation
Adhere to Medicaid, Office of Mental Health and Health Homes billing standards
Secure all health records and other protected information with the highest regard to confidentiality and HIPPA laws and regulations
Provide each member of the caseload with a minimum of four health home core services per month, including but not limited to face to face, at home visits and telephonic contact
Engage families, natural supports, and providers into the care coordination process