Care Manager

POSITION SUMMARY

Provides care management services to specific population eligible for Health Home services. Provides information, referrals, and/or care management on health and psychosocial issues.

This position works with substantial independence in the field, with consultation available from Team Lead and/or Supervisor, as needed.

ESSENTIAL JOB DUTIES/FUNCTIONS

% of Time

Essential Function

50%

Care Management

• Receives referrals of members for Health Home services from internal and external sources.

• Contacts referral within appropriate timeframe, addresses any urgent /emergent issues and schedules an appointment for a face-to-face intake, within required time frame.

• Conducts comprehensive bio-psycho-social assessments for adults and/or children using NYS and agency approved processes and documents.

• Develops therapeutic relationship with member utilizing person centered interventions based on the member’s level of activation and presenting conditions.

• Coordinates services through communication with all identified health and community providers/agencies connected to the member.

• Develops a Person-Centered Plan of Care with the member and involved providers.

• Disseminates this information to all individuals who are involved in members’ care, as approved by member.

• Interviews referrals and their families to collect data, disseminate pre-approved health education information.

• Determines need and makes recommendations for continuation of or change in services.

• Maintains, at minimum, monthly telephonic contact with the member and an in-person visits at minimum once every three months. Contacts may be more often depending upon the acuity and/or complexity of the member’s current condition or situation. If staff manage members that are in a program that requires a higher level of engagement such as Health Home Plus or Children’s, the required number of contacts and core services are made. Seeks out consultation/information for complex medical, behavioral health or psycho-social needs, as needed.

• Recognizes cultural differences, demonstrates responsiveness to those differences when working with members and others in the community.

• Travels as required for home visits and other community activities.

• Adheres to Elm & Oak Health professional boundaries and protocols.

30%

Documentation

• Completes all required documentation in a complete, clear, concise and timely fashion insuring that the information presented is readily understood and actionable by team members.

• Must show aptitude in software platforms used within the program within 3 months of initial training and/or 6 months of hire, whichever comes first.

• Completes all necessary assessments to include a comprehensive assessment as required by the Health Home hub, Health Home authorization, HML assessment within regulatory time frames, and any other documentation requirements as defined by each Health Home hub.

• Documentation of a Person-Centered Care Plan, in collaboration with the client and providers

• Review and update of assessments, as mandated by regulations.

• Maintains documentation that is thorough, clearly written, and reflective of members’ plan of care activities. Documentation needs to be completed at minimum 1x/month and more often as contacts and actions occur in the members’ case and/or as needed for specific program requirements.

• Documents in electronic record regarding care management/coaching activities and termination as appropriate.

15%

Collaboration

• Participates as a member of multi-disciplinary Care Management team.

• Initiates and facilitates member focused meetings to include the member, community providers and significant others, as identified by member for the purpose of care coordination and establishment of a natural support group.

• Participates in inter-agency teams to enhance the work environment and provision of services for members.

• Participate effectively as a team member within the Elm & Oak Health team by fostering a positive working relationship with members, providers, and Monroe Plan staff; working effectively with others to coordinate member and access care support services; supporting team members for cross coverage as workload dictates.

• Collaborate with other members of Health Home staff related to member needs, barriers to care and outcome enhancement strategies.

• Manages conflict to support a positive outcome.

• Participate in community activities to promote health and public awareness using Elm & Oak Health specified materials.

• Assists in locating members in the community through home visits and collaboration with known providers.

• Attend and participate in in-service training.

10%

Communication

• Presents in a professional and articulate manner that supports the development of a therapeutic relationship with the member and community providers.

• Provide feedback to providers regarding the progress made and barriers encountered by their patients.

• Demonstrates listening skills to support member engagement and development of a person-centered plan of care.

• Provide program information to members and providers, and other organizations as requested to introduce and support program participation.

OTHER FUNCTIONS AND RESPONSIBILITIES

Position Limitations:

-Cannot perform any tasks which are governed by license or registration (i.e. cannot answer questions or make recommendations RE diagnosis, medications or treatment).

-Cannot transport active Monroe Plan members at any time.

-Cannot perform hands on care.

MINIMUM REQUIREMENTS/LICENSES/CERTIFICATIONS

• Master's degree in Social Work, Psychology, Nursing, Rehabilitation, Education, OT, PT, Recreation, Counseling, Community Mental Health, Child & Family Studies, Sociology, Speech & Hearing or other Human Services field AND 1 year of experience providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse and/or children with SED; or 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.
• Bachelor's degree in Social Work, Psychology, Nursing, Rehabilitation, Education, OT, PT, Recreation, Counseling, Community Mental Health, Child & Family Studies, Sociology, Speech & Hearing or other Human Services field AND 2 years of experience providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse and/or children with SED; or 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.
• Credentialed Alcoholism and Substance Abuse Counselor (CASAC) AND 2 years of experience providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse and/or children with SED; or linking individuals with Serious Mental Illness, children with SED, developm