Health Home Care Manager

Job Summary: The Health Home Care Manager (HHCM) is required to have a detailed understanding of the health focused work and is primarily responsible for assessments, service plan development, case coordination, linking and advocacy; monitoring, and clinical consultation. Their focus is on coordinating and arranging for the provision of services; supporting adherence to treatment recommendations; and monitoring and evaluating a member's needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care. The HHCM is expected to use an individualized care service delivery approach ensuring the services are designed to address the unique needs and strengths of each member. Essential Job Functions: Provide the six core services for health home management for all members on their caseload in conjunction with acuity Comprehensive Care Management Care Coordination and Health Promotion Comprehensive Transitional Care Patient and Family Support Referral to Community and Social Support Services Use of Health Information Technology (HIT) to Link Services Complete required Face to Face contacts Complete all required HHCM documentation including but not limited to Plan of Care (POC), Medicaid CANS, and progress notes into the Health Home IT platforms within the required time frames Assist members in understanding POCs and instructions and tailoring communications to appropriate health literacy levels Ability to work from a team approach and provide coverage as needed Work collaboratively with all relevant stakeholders to assess the member's needs for HH services Link the member to any and all identified services Conduct member outreach and engagement activities, including face to face, mail, electronic and telephone contact Participate in all required internal and external trainings Attend care planning meetings, ad hoc meetings, and supervision In tandem with the rollout of Medicaid Managed Care, ability to review, adhere, collaborate and coordinate with all Managed Care Organizations (MCOs), State Plan Amendment (SPA), and Home Community Based Services (HCBS) Providers on reviewing the POC and ensuring the delivery of the appropriate provision of services Maintain member records in line with agency policies Ability to be flexible with programmatic needs and changes For all foster care cases, monthly contact required with the case planning team Other duties as assigned Education and Experience Required: A Bachelors of Arts or Science with two years of relevant experience, or a licensed practicing nurse (LPN) with four years of relevant experience, or registered nurse. Relevant experience includes providing service coordination and information, linkages, and referrals for community-based services to children with special needs andor complex trauma, individuals with disabilities. Solid organizational and follow-up skills Computer Literacy -learn and adapt to different IT platforms Excellent interpersonal skills Ability to manage and work with a variety of different people Flexibility to travel throughout NYS Maintain Confidentiality Capable of clear direct communication with others (oral and written) Knowledge and Skills Preferred: Engagement and Outreach Safety in the Community Person Centered Planning Cultural CompetencyAwareness Addressing LGBTQ concerns Physical Requirements: Ability to travel to via public transportation to complete home visits Repetitive movement of hands and fingers (typingandor writing); visual acuity to view documents on a computer screen for long periods of time Ability to frequently communicate with membersemployees who have inquiries about available services. Must be able to exchange accurate information in these situations. Required CertificationLicensing: Medicaid CANS certification and on-going recertification Mandated Reporting Trauma Informed Care All other required trainings Salary Range: $48,000-$50,600

Created: 2025-02-24