The Health Home Care Manager has the responsibility of assisting eligible families, children and youth to provide access to services assuring they have everything necessary to stay healthy, out of the emergency room and out of the hospital. The Care Manager acts as a liaison in linking supports and services that a child and their family may benefit from. The Care manager will assist families in obtaining new services and providers as needed and assist them in developing supports following a person-centered approach. The care manager will follow all policies as outlined by the Contracted Health Home Agency- Children’s Health Home of Upstate New York (CHHUNY).
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To carry a caseload of youth with varying needs and have face-to-face contact with child/ youth as determined by need and acuity and to provide documentation in contact notes as necessary. Responsible for maintaining a full caseload with mixed acuity.
May have a caseload providing services to individuals across several counties and build comprehensive supports teams for youth.
- Complete outreach and enrollment- Health Home Care Managers are expected to provide, and document, progressively intensive and meaningful outreach activities with the child/youth (if appropriate with appropriate consent) or their parent/guardian/legally authorized representative (with appropriate provisions to assure patient privacy is protected). Determine eligibility based on the DOH eligibility guidelines.
- Core services/ Documentation- Health Home Care Managers to provide comprehensive Core Services: Comprehensive Care Management; Care Coordination and Health Promotion; Comprehensive Transitional Care; Member & Family Support; and Referral; Community & Social Support; and he use of HIT to link services, as feasible and appropriate. The Care Manager is responsible to document all core services in the electronic record.
- CANS-NY-The Health Home Care Manager will complete Annual Certification and training with a passing score. 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.
- Supports-Provide supports and services as indicated by the acuity level and the needs identified for the child/ youth and his/ her family.
- Plan of Care- The Health Home Care Manager will use other assessment and information obtained from the multi-disciplinary team to complete the Plan of Care. The Health Home 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 60 days from the date of enrollment and revise at minimum every 6 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 the primary care physician/nurse practitioner, specialist(s), behavioral health care(s), care manager and other providers directly involved in the individual's care.
- Emergency and Crisis Plan- The Health Home Care Manager and member will develop a child/youth focused and family driven client crisis intervention plan within 60 days of enrollment.
- Advocate- The Health Home Care Manager will advocate for services, and ensure the availability of priority appointments for Health Home enrollees for medical and behavioral health care services within their Health Home provider network to avoid unnecessary, inappropriate utilization of emergency room and inpatient hospital services.
- A Bachelors of Arts or Science with 2 years of relevant experience, or
- A License as a Registered Nurse with 2 years of relevant experience, or
- A Masters with one year of relevant experience
- Ability and temperament to work effectively with people with Behavioral Health, intellectual and physical disabilities is required
- Valid driver’s license that is in compliance with Heritage Christian Services’ motor vehicle record standards
- Reliable Internet connection
Our Commitment to Equity and Justice
We believe that people are entitled to dignity, respect, equity and justice. We champion a society that removes barriers. We reject racism and discrimination of any kind. We protest systemic and political inequities that marginalize people, recognizing that there is a history of structural racism in the United States. We will continue to learn and change to achieve justice. We know that strength comes from unity. As you speak out, be strong, faithful and well.