Care Manager - Health Home

Location: Middletown, NY Must be willing to travel to different counties Pay Rate: $24.04/hr.  Hours: Monday-Friday 8:30AM-5:00PM or 9:00AM-5:30PM (40hrs). Flexibility required to meet the needs of the individuals.    OVERVIEW OF PRIMARY RESPONSIBILITIES: Care management is a promising team-based, patient-centered approach designed to assist individuals and their support systems in managing their healthcare more effectively. It encompasses care coordination activities that support all social determinants of health needs.   The care manager is a core member of a collaborative team, including the individual’s medical and behavioral health providers, as well as the larger care team including, but not limited to, housing, substance use treatment, family/care givers, and other community services. The care manager coordinates the care of individuals with chronic disease, behavioral health, and significant barriers to health, by assessing them to receive timely, comprehensive care, and supporting them in achieving their personal health and life goals.   Care managers provide services to individuals who are Medicaid recipients as well as people who are not eligible for Medicaid.   PRIMARY FUNCTIONS: Manage care coordination related to all health care services and social determinants of health needs. Facilitate engagement, follow-up care, and connections. Assist in navigating the healthcare system. Collaborate with all of the involved providers both internally and externally. Track follow-up and outcomes using a caseload log/excel spreadsheet. Ensure all pertinent information is included in the individual’s record in the Health Home Electronic Health Record (EHR). Document all in-person and telephone encounters in the record. Document care plan goals, progress, and ongoing assessments in the record. Facilitate treatment plan changes for individuals who are not improving as expected, in consultation with their care team. Work as a partner to design and implement care plan goals to overcome barriers and improve health outcomes. Facilitate referrals for services outside of the organization (e.g., social services such as housing assistance, vocational rehabilitation, mental health, specialty care, substance abuse treatment). Educate about illness and positive lifestyle changes and motivate them to adhere to necessary treatments. Educate on the importance of preventative measures. Visit people in their homes and communities as needed. Conduct full intakes for care management services. Act as an advocate for individual’s rights. Establish and maintain community resources as needed. Provide 24/7 coverage as needed for people on your caseload.   ADDITIONAL FUNCTIONAL / ORGANIZATIONAL SUPPORT: Perform other related duties as assigned   QUALIFICATIONS AND ATTRIBUTES: Valid and unrestricted driver’s license Must be willing to travel to multiple counties Highly organized with excellent oral and written communication skills Ability to maintain a non-judgmental disposition and communication with a diverse population Effective verbal and written communication skills Proficient technology and computer skills including internet, email, word processing, spreadsheets, electronic health records, and databases. The ability to use technology to communicate effectively and professionally, and organize information. Demonstrated ability to collaborate and communicate effectively in a team setting Ability to maintain effective and professional relationships Working knowledge of differential diagnosis of common mental health and/or substance abuse disorders Ability to work by telephone as well as in person   EDUCATION AND EXPERIENCE: Bachelor’s degree in Health and Human services or related field                                                     or Bachelor’s level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses                                                     or Credentialed Alcoholism and Substance Abuse Counselor (CASAC)                                                     or Master’s degree with one year of experience   Bilingual (English/Spanish speaking) preferred   PHYSICAL CHARACTERISTICS: These physical demands are representative of the physical requirements necessary for an employee to perform the job's essential functions successfully. Reasonable accommodation can be made to enable people with disabilities to perform the described essential functions of the position, which are reviewed in each case.