Health Home Plus Care Manager

Position Type: Full-Time (37.5 hours per week, 52 weeks per year) – Grade 14

Monday through Friday – 8:30 am to 4:30 pm

JOB SUMMARY :

This role provides meaningful, hands-on support to people of all ages across Oswego County. Using OCO’s Universal Service Delivery model, the position delivers early intervention and care management services in homes, community locations, partner agencies, and OCO offices. The Care Manager works independently, supports key program functions, and helps individuals and families access the resources they need—while upholding all Agency and Program policies and procedures.
What You’ll Do:

As a Health Homes Care Manager, you will:

• Provide consumer-centered, non-judgmental crisis intervention and support to individuals with complex medical, behavioral, or social needs.
• Manage a caseload of approximately 35 Medicaid-eligible members, ensuring timely and appropriate engagement.
• Conduct comprehensive assessments and develop individualized Health Action Plans addressing medical, behavioral health, and social determinants of health.
• Coordinate with healthcare providers, community agencies, and service systems to help participants meet their health goals.
• Advocate for participants by providing accompaniment, information-sharing, and ongoing support.
• Follow up on referrals to ensure needs are met and barriers are addressed.
• Provide or coordinate transportation to connect individuals with essential resources and services.
• Maintain accurate documentation, electronic health records, and billable service notes within required timeframes.
• Ensure billing records and caseload distribution support program efficiency and reimbursement guidelines.
• Represent OCO at community meetings, collaborate with partners, and support program operations as a leader within the team.
• Adhere to all NYSDOH, HIPAA, Health Home Program, and agency regulations.
• Participate in trainings, staff meetings, and skill-building activities to support ongoing professional growth.

JOB REQUIREMENTS :

• Ability to build strong, respectful, and collaborative relationships with individuals, families, and community partners.
• Ability to effectively support people with mental health needs, substance use challenges, chronic health conditions, and complex social situations.
• Strong verbal and written communication skills, with the ability to communicate clearly, compassionately, and professionally.
• Excellent documentation and data-entry skills, including the ability to manage and interpret complex information.
• Ability to work independently and as part of a team; organized, flexible, resourceful, and able to manage multiple priorities.
• Commitment to maintaining confidentiality, professionalism, sound judgment, and ethical conduct at all times.
• Willingness and ability to travel throughout the county to meet consumers in various community settings and transporting consumers.
• A valid NYS Driver’s License with an acceptable driving record, and reliable, insured transportation for regular travel.
• Acceptable health to perform responsibilities of the position.

MINIMUM QUALIFICATIONS :

Candidates must meet one of the following qualification paths:

• Bachelor’s degree in Social Work, Nursing (RN), Public Health, Counseling, Psychology, Human Services, or a related field with experience in care coordination or case management , OR
• Associate degree/certification in a related field plus additional relevant experience, OR
• An equivalent combination of education, experience, and training.
• 1–3 years of experience in care coordination, case management, behavioral health, chronic disease management, or related work is preferred.

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Oswego County Opportunities, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, creed, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, marital status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

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