GA Family Services - Health Home Care Manager - Full Time

Purpose: The Health Home Care manager has the overall responsibility and accountability for coordinating all aspects of the member's care, ensuring compliance with delivery of the Core Health Home Services.  The Care Manager is also responsible in documenting all core services in the electronic record.  

Qualifications: 

• Bachelor’s Degree in related field with relevant experience considered.  Master’s degree in social work preferred
• Valid NYS Driver’s License required.
• Successful Completion of CANS-NY upon provisional hiring, Mandated Reporter Training, Netsmart Care Manager Training 

Job Duties:

• Care Manager will conduct outreach and engagement activities to assess client needs and to promote Health Home enrollment. Initial contact occurs within five days of assignment.
• Care Manager will determine client eligibility for Health Homes and secure supporting documentation
• Care Manager will complete the client enrollment process and obtain all required consents from the medical consenter. In cases where the client chooses to opt-out, all required documentation will be completed
• Care Manager will complete the Child and Adolescent Needs and Strengths assessment for New York State (CANS-NY) within 30 days of enrollment, and again every six months. If the member goes through a major life change, the Department of Health requires the assessment be redone.
• Care Manager and member will develop a child/youth focused and family driven client safety and crisis plan and emergency plan within 30 days of enrollment.
• Care Manager will create a child/youth centered and family driven plan of care with the member to identify member’s needs/goals and include family members and other social supports as appropriate within 30 days of completion of the CANS-NY and revise every 3 months. The child/youth’s plan of care must integrate the continuum of medical, behavioral health services, rehabilitative, long term care and social service needs and clearly identifies and integrates the primary care physician/nurse practitioner, specialist(s), behavioral health care provider(s), care manager and other providers directly involved in the individual's care.
• Care Manager will develop, review and revise the child/youth’s plan of care with the child/parent/legal guardian/family to ensure that the plan reflects the child and family’s preferences, education and support for self-management to improve adherence to prescribed treatment.
• Care Manager will meet with the child/youth and family (including LDSS Case Manager and VFCA Case Planner for children in Foster Care), inviting any other providers to facilitate needed interpretation services. Meetings should accommodate family schedules to ensure that family members have the ability to participate (as appropriate).
• Care Manager will consult with primary care physician and/or any specialists involved in the treatment plan, including timeframes for improving the member's health and identifying interventions that will produce the desired effect.
• Care Manager will assist with linking the child/youth with community supports to assure that needed services are provided
• Care Manager will provide on-call duties within the agency to provide information and emergency consultation services. For children in Foster Care, after hours calls will be reported to the Voluntary Foster Care Agency (VFCA) Case Planner
• Care Manager supports adherence to treatment recommendations
• Care Manager coordinates with service providers and health plans as appropriate to secure timely access to necessary care, share crisis intervention and emergency information.
• Care Manager will assist with linking the child/youth or making referrals to needed services to support care services, and support care plan/treatment goals, including medical/behavioral health care; patient education and self-help, recovery and self-management.
• Care Manager will schedule and/or attend regular case reviews with all members of the interdisciplinary team to monitor/evaluate the child/youth’s condition and determine necessary treatment and service changes. For children in foster care, this will be done on a schedule determined in collaboration with the Local Department of Social Services (LDSS), VFCA and Health Home Care Manager.
• Care Manager monitors, supports and may accompany the child/youth and family to scheduled medical appointments.
• Care Manager will respond to a child/youth’s crisis, intervene as appropriate and revise care plan and/or crisis plan if indicated
• Care Manager ensures continuity of care and comprehensive transitional care from service to service (education, foster care, juvenile justice, child to adult)
• Care Manager will follow up with hospitals or emergency rooms upon notification of a child/youth’s admission and/or discharge to/from an emergency room, hospital, residential or rehabilitative setting.
• Care Manager will follow up within 48 hours post discharge with child /family/legal guardian/parent to assist with care plan needs and modify goals and interventions when appropriate.
• Care Manager facilitates timely access to follow-up care post discharge from hospital, emergency room, or residential/rehabilitation setting. This includes:
  1. Receipt of a summary of care record from the discharging entity
  2. Medication reconciliation
  3. Timely scheduled appointments with recommended outpatient providers and identification of potential obstacles to attending follow up visits
  4. Verification with outpatient providers that the child/youth attended the appointment as well as a plan to outreach and re-engage in care if the appointment was missed
• For children in Foster Care, the Care Manager ensures ongoing care and seamless transitional planning (i.e. Medicaid coverage, linkage with health care providers) upon discharge from foster care
• Care Manager ensures all members of the multidisciplinary team are aware of admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting
• Care Manager will consult with the child/youth, the family and/or legal guardian on advanced directives and educate on client rights and health care issues, as needed.
• All services provided by a Care Manager are documented within CHHUNY’s designated electronic record (Netsmart CareManager) within prescribed timeframes.
• Care Manager will compete required contacts: 

     A. For High and Medium acuity children: 2 Health Home services per month, 1 of which is face-to-face encounter with the child/youth.

     B. For Low acuity children: 1 Health Home service per month, multiple modality options.

• Care Manager completes monthly eligibility screening for all clients

GAFS Organizational Responsibilities:

• Engages in regular supervision with own supervisor, including scheduled evaluations
• Actively participates in all in-service programs and scheduled meetings during your on-days
• Maintains ongoing and open communication with team members and promotes relationships of trust and respect with residents and staff
• Fulfills obligations inherent in the major systems of the GAFS and the LSS Human Resources Policies
• Demonstrates a commitment to organizational and department goals
• Shares positive and negative information directly with team members and confronts others; to utilize the organizational chain of command
• Practices good listening skills and communicates well both in writing and verbally
• Demonstrates personal and professional ethics, attitudes and value systems which enhance team functioning and to abide by the Standards of Confidentiality
• Upholds child and family rights as outlined in State Office of Child and Family Services mandates and GAFS procedures

We can’t wait to hear from you!

 Lutheran Social Services is an equal opportunity employer that is committed to diversity and inclusion in the workplace. 

We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, 

genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.