Health Home Care Manager I

Job Description

Job Description

Role and Responsibilities 

The Health Home Care Manager will provide collaborative, client-centered support to Health Home Program clients using the development of person-centered goals, culturally competent care management, and professional healthcare and social service coordination. Health Home Care Managers will evaluate, manage, and integrate solutions and resources for all primary, complex chronic diseases, behavioral health and long-term care needs in the Health Home Program.  

Essential Functions 

• Actively and progressively care manage an enrolled client caseload as determined by Agency guidelines.  Develop individualized plans of care with specific goals/interventions/objectives, to be revised as needed. 
• Provide rehabilitative and supportive counseling geared toward the restoration of clients to their optimum level of social and health functioning.  This includes assisting clients and their families with the adjustment to their illness and following medical/behavioral health recommendations. 
• Assist the clients and their families with personal and environmental difficulties, which predispose them towards illness and/or interfere with obtaining maximum benefits from medical care. 
• Develop long- and short-term plans, when appropriate, including the utilization of community supports with the goal of reducing emergency room and/or in-patient utilization. 
• Communicate directly with members of the care team to provide up-to-date information regarding the client’s care to effectively reduce duplicative services. 
• Consult with the physicians, Managed Care Organizations and other members of the Care Team for the purpose of educating them on the social, emotional and environmental factors related to the client’s barriers to success. 
• Prepare concise, accurate, and timely case notes which are incorporated into the client’s records. 
• Complete client documentation within 24-