Health Home Plus Care Manager

Minimum Qualifications:

· Education: 1. A bachelor’s degree in a qualifying field or 2. A NYS teacher’s certificate for which a bachelor’s degree is required; or 3. NYS licensure and registration as a Registered Nurse and a bachelor’s degree; or 4. A Bachelor’s level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses; or 5. A Credentialed Alcoholism and Substance Abuse Counselor (CASAC).

· Experience: Two years: 1. In providing direct services to people with Serious Mental Illness, developmental disabilities, or alcoholism or substance abuse; or 2. In linking individuals with Serious Mental Illness, developmental disabilities, or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services). A master’s degree in one of the listed education fields may be substituted for one year of Experience.

The Health Home Plus Care Manager provides intensive care coordination services to clients with Serious Mental Illness. The Health Home Plus Care Manager is expected to promote independence and ready their Clients for step down into regular Care Management by assisting clients with understanding and navigating the medical, behavioral and social services systems through the completion of assessments, crisis plans and plan of care. The Health Home Plus Care Manager will engage the Clients in a person-centered approach to link clients to necessary supports in the community, including member family support, providers and peer services. Ongoing collaboration with community partners, providers and supports systems is essential to ensure best health care outcomes.

Duties

1. Responsible for, but not limited to comprehensive assessment, outreach and engagement, service and treatment linkages and coordination using evidence-based practices and outcomes.

2. Conduct appropriate screening and either performing or arranging for more detailed assessments when needed (e.g., high-risk substance use or mental health related indicators, harm to self/others, abuse/neglect and domestic violence).

3. Plan and coordinate care management needs for high-need SMI individuals including:

o Navigating the mental health service system-including ability to make referrals to mental health housing services, crisis intervention/ diversion, peer support services o Knowledge of the behavioral health managed care benefit package.

o Collaborates with inpatient staff and MCO (as applicable) to affect successful transitions out of inpatient or institutional settings.

o Addressing the quality, adequacy and continuity of services to ensure appropriate support for individuals’ mental health and psychosocial needs

o Completing plans of care and coordinating with MCOs for HARP members utilizing the Home and Community Based Services (HCBS) benefit package

4. Maintain engagement with individuals who are often disengaged from care, have difficulty adhering to treatment recommendations, or have a history of homelessness, criminal justice involvement first-episode psychosis and transition-age youth. Key skills and practices to engage high-need SMI individuals include:

o Motivational Interviewing

o Suicide Prevention

o Risk Screening

o Trauma Informed Care

o Person-centered care planning and interventions

o Recovery-Oriented Approaches (e.g., WRAP).

5. Build and use effective communications strategies among peers, medical staff, addiction and mental health providers and other community agencies through the use of electronic assisted devices including Telehealth and other interactive technology.

6. Help improve, measure, monitor, and sustain quality outcomes that focus on clinical indicators/performance measures, patient satisfaction, and plan adherence.

7. On-Call duties as assigned for nights and weekends.

Job Type: Full-time

Benefits:

• 403(b)
• Dental insurance
• Employee assistance program
• Health insurance
• Health savings account
• Life insurance
• Mileage reimbursement
• Paid sick time
• Paid time off
• Vision insurance

Medical specialties:

• Home Health

Schedule:

• Monday to Friday

Work setting:

• Clinic

Ability to commute/relocate:

• Shortsville, NY: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Case management: 1 year (Preferred)

Willingness to travel:

• 25% (Preferred)

Work Location: In person

Salary : $40,600 - $51,400