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 PromotionComprehensive Transitional CarePatient and Family SupportReferral to Community and Social Support ServicesUse of Health Information Technology (HIT) to Link ServicesComplete required Face to Face contactsComplete 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 framesAssist members in understanding POCs and instructions and tailoring communications to appropriate health literacy levelsAbility to work from a team approach and provide coverage as neededWork collaboratively with all relevant stakeholders to assess the member's needs for HH servicesLink the member to any and all identified servicesConduct member outreach and engagement activities, including face to face, mail, electronic and telephone contactParticipate in all required internal and external trainingsAttend care planning meetings, ad hoc meetings, and supervisionIn 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 servicesMaintain member records in line with agency policiesAbility to be flexible with programmatic needs and changesFor all foster care cases, monthly contact required with the case planning teamOther duties as assignedEducation 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 and / or complex trauma, individuals with disabilities.Solid organizational and follow-up skillsComputer Literacy -learn and adapt to different IT platformsExcellent interpersonal skillsAbility to manage and work with a variety of different peopleFlexibility to travel throughout NYSMaintain ConfidentialityCapable of clear direct communication with others (oral and written)Knowledge and Skills Preferred :
Engagement and OutreachSafety in the CommunityPerson Centered PlanningCultural Competency / AwarenessAddressing LGBTQ concernsPhysical Requirements :
Ability to travel to via public transportation to complete home visitsRepetitive movement of hands and fingers (typing / and / or writing); visual acuity to view documents on a computer screen for long periods of timeAbility to frequently communicate with members / employees who have inquiries about available services. Must be able to exchange accurate information in these situations.Required Certification / Licensing :
Medicaid CANS certification and on-going recertificationMandated ReportingTrauma Informed CareAll other required trainingsSalary Range : $48,000-$50,600
Salary : $48,000 - $50,600
