HHCM CC

Adult Health Home Care Manager

Job Description

Job Summary:

The Adult Health Home Care Manager is a full-time position that works with and oversees the process

with individuals to develop and maintain a person-centered comprehensive plan for accessing and using

services and supports necessary for a person’s health.

Educational qualifications:

• Qualified candidates should have a bachelor’s degree with a major or concentration in social

work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy,

recreation or recreation therapy, counseling, community mental health, child & family studies,

sociology, or speech and hearing; OR a NYS teacher’s certificate for which a bachelor’s degree is

required; OR NYS licensure & registration as a Registered Nurse & a bachelor’s degree; OR a

master’s degree in social work, psychology, nursing, rehabilitation, education, occupational

therapy, physical therapy, recreation or recreation therapy, counseling, community mental

health, child & family studies, sociology, or speech and hearing AND two years of experience in

providing direct services to mentally disabled individuals or in linking mentally disabled

individuals to a broad range of services essential to successfully living in a community setting

(e.g., medical, psychiatric, social, educational, legal, housing, and financial services). *Master’s

degree may substitute two years of experience.

Other position specific qualifications:

• Reliable and trustworthy, sound decision-making skills
• Demonstrated ability to serve individuals in a professional, welcoming, and efficient manner.
• Cooperative, friendly, and helpful attitude with individuals and co-workers. Ability to work

closely with other employees to ensure a positive, constructive environment within individual

programs and overall agency.

• Ability to work independently and in a team setting.
• Ability to maintain confidentiality regarding the agency’s functions and individuals receiving

services.

• Must positively promote the agency within the community.
• Must be detail oriented.
• Must be able to clear NYS Criminal Justice Background Check, Office of Children and Families

Background Check, Department of Health Background Check, and clear the NYS staff exclusion

list, OIG, and HHS-OIG.

• Ability to maintain a flexible schedule with availability to work weekends and/or evenings, as

needed.

• Must be willing to learn and self-improve.
• Must be willing to travel 50% or more per week.
• Must have and maintain reliable transportation including a valid driver’s license, registration,

inspection, and insurance.

Job Responsibilities:

• Assures that Health Home enrollees receive needed medical, behavioral, and social services with

the overarching goal of improving individual health outcomes.

• Must engage 80% of individuals referred for health home care management services within a

30-day period.

• Assumes overall responsibility and accountability for coordinating all aspects of the individual’s

care.

• Provides care management services at various community locations and individual’s homes.
• Leads multidisciplinary teams of medical, mental health, chemical dependency treatment

providers, social workers, nurses, and other care providers toward assuring individuals receive

services.

• Explores with the individuals their immediate needs and their longer-term goals and vision for

their recovery.

• Assesses needs, monitors progress with individual/legal representative and care team, modifies

or updates the care plan or goals.

• Assists in scheduling and keeping appointments, advocates and arranges for needed services

and monitors delivery of services.

• Evaluates care needs at transitions, arranges safe transition plans, updates care team, updates

information with providers and care plans.

• Activities including promoting self-management, facilitating family/legal representative

meetings, seeking peer supports and educating individuals of their rights.

• Identifies community networks and supports that will be utilized to address needs.
• Must keep up to date accurate records in Netsmart to be compliant with all AHI’s mandates and

requirements.

• Must bill accurately and ethically every month, with 90% or more of billing completed by the

end of the 3rd week of the month.

• Must be able to engage and re-engage individuals to ensure positive outcomes. Must maintain

and 85% or higher engagement level monthly.

• Must correct any noncompliance brought forth within a 21-day period.
• Must complete Mandated Reporting, HIPAA (Health Insurance Portability and Accountability),

Safety in the Community, Engagement & Outreach, Person Centered Planning, Cultural

Competency/Awareness, LGBTQ Issues, Meeting Facilitation, Health Home Netsmart, and

Trauma training within the first week of employment.

• Must obtain New York State Peer Specialist Certification within 6 months of hire date.
• Must obtain an additional 10 hours of CEUs annually after receipt of New York State Peer

Specialist Certification to maintain credentials.

• Must be able to abide by all agency policies and procedures.
• Must adhere to professional boundaries with fellow employees, individuals receiving services

and partner agency employees.

• Must be able to maintain confidentiality of individuals worked with and agency functions.
• Must attend required meetings and or training requested by the agency and or partner agency.

Other Duties

• Please note this job description is not designed to cover or contain a comprehensive listing of

activities, duties, or responsibilities that are required of the employee for this job. Duties,

responsibilities, and activities may change at any time with or without notice.