Care Manager II - Health Home

Elm & Oak Health – Care Manager – Binghamton Region – full time, work from home. Travel within Binghamton Region will be required. Position Summary Provides care management services to specific populations eligible for Health Home services. Offers information, referrals, and care management on health and psychosocial issues. Essential Job Duties and Functions 50% – Care Management Receives referrals of members for Health Home services from internal and external sources. Contacts referral within appropriate timeframe, addresses any urgent/emergent issues and schedules an appointment for a face-to-face intake. Conducts comprehensive bio‑psycho‑social assessments for adults and/or children using NYS and agency approved processes and documents. Develops therapeutic relationship with member utilizing person‑centered interventions based on the member’s level of activation and presenting conditions. Coordinates services through communication with all identified health and community providers/agencies connected to the member. Develops a Person‑Centered Plan of Care with the member and involved providers. Disseminates this information to all individuals involved in members’ care, as approved by member. Interviews referrals and their families to collect data, disseminate pre‑approved health education information. Determines need and makes recommendations for continuation of or change in services. Maintains, at minimum, monthly telephonic contact with the member and in‑person visits at minimum once every three months; contacts may be more frequent depending on acuity or complexity. Seeks out consultation/information for complex medical, behavioral health or psycho‑social needs, as needed. Recognizes cultural differences, demonstrates responsiveness to those differences when working with members and others in the community. Travels as required for home visits and other community activities. Adheres to Elm & Oak Health professional boundaries and protocols. 30% – Documentation Completes all required documentation in a complete, clear, concise and timely fashion. Shows aptitude in software platforms used within the program within 3 months of initial training and/or 6 months of hire. Completes all necessary assessments as required by the Health Home hub, Health Home authorization, HML assessment and any other documentation requirements. Documents a Person‑Centered Care Plan in collaboration with the client and providers. Reviews and updates assessments as mandated by regulations. Maintains thorough, clearly written, and reflective documentation; minimum 1x/month. Documents in electronic record regarding care management/coaching activities and termination as appropriate. 15% – Collaboration Participates as a member of multi‑disciplinary Care Management team. Initiates and facilitates member focused meetings with the member, community providers and significant others. Participates in inter‑agency teams to enhance services. Collaborates with other Health Home staff regarding member needs, barriers to care and outcome enhancement strategies. Manages conflict to support a positive outcome. Participates in community activities to promote health and public awareness. Assists in locating members in the community through home visits and collaboration with known providers. Attend and participate in in‑service training. 10% – Communication Presents in a professional and articulate manner that supports the development of a therapeutic relationship. Provides feedback to providers regarding the progress and barriers encountered by their patients. Demonstrates listening skills to support member engagement and development of a person‑centered plan of care. Provides program information to members, providers, and other organizations as requested. Other Functions and Responsibilities Any other duties consistent with effective performance of the role. Position Limitations Cannot perform tasks governed by license or registration (e.g., diagnosing, prescribing medications). Cannot transport active Monroe Plan members at any time. Cannot perform hands‑on care. Minimum Requirements / Licenses / Certifications Master’s degree in Social Work, Psychology, Nursing, Rehabilitation, Education, OT, PT, Recreation, Counseling, Community Mental Health, Child & Family Studies, Sociology, Speech & Hearing or other Human Services field AND 1 year of experience providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse and/or children with SED; or linking individuals with these conditions to a broad range of services. Bachelor’s degree in the same fields AND 2 years of experience providing direct services or linking individuals with these conditions. Credentialed Alcoholism and Substance Abuse Counselor (CASAC) AND 2 years of experience providing direct services or linking individuals with these conditions. Bachelor’s degree or higher in any field AND 3 years of experience providing direct services or linking individuals with these conditions, or 2 years of experience as a Health Home Care Manager serving the SMI or SED population. Demonstrated ability to respect individual/family diversity and maintain confidentiality. Demonstrated ability to work as a team member. Knowledge of and ability to work collaboratively with providers and county/community health and human services. Excellent communication skills both oral and written; strong interpersonal skills. Proven ability to work independently and manage time appropriately. Strong organizational skills. Computer literate. NYC driver’s license and reliable transportation for travel requirements. Preferred Qualifications Previous experience working as a Health Home Care Manager. PHI Minimum Necessary Use PHI access will be determined based on Minimum Necessary standards. Refer to the Minimum Necessary Grid on the Human Resources and Compliance Web pages. This job description is only a summary of the typical functions of the job, not an exhaustive or comprehensive list of all possible responsibilities, tasks and duties. Additional responsibilities, tasks and duties may be assigned as necessary. Elm & Oak Health is an Equal Opportunity Employer. #J-18808-Ljbffr