Description

This is a work from home opportunity that requires frequent home visits with clients and other community travel. Candidates must live in the Capital Region of NYS.

POSITION SUMMARY

Provides care management services to specific population eligible for Health Home services. Provides information, referrals, consultation and/or care management on health and psychosocial issues.

This position works with substantial independence in the field, with consultation available from Team Lead and/or Supervisor, as needed.  

ESSENTIAL JOB DUTIES/FUNCTIONS

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, within   required time frame.
• 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 who are 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 an in-person visits at minimum once every three months.  Contacts may be more often depending upon the acuity and/or complexity of the member’s current condition or situation. If staff manage members that are in a program that requires a higher level of engagement such as Health Home Plus or Children’s, the required number of contacts and core services are made. 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 Monroe Plan professional boundaries and protocols.

 
Documentation

• Completes all required documentation in a complete, clear, concise and timely fashion insuring that the information presented is readily understood and actionable by team members.
•  Must show aptitude in software platforms used within the program within 3 months of initial training and/or 6 months of hire, whichever comes first. 
•  Completes all necessary assessments to include, but not limited to the Health Assessment Tool or other comprehensive assessment as required by the Health Home hub, Patient Activation Measure (PAM) for HHUNY and GRHHN members, Health Home authorization, HML assessment within regulatory time frames, and any other documentation requirements as defined by each Health Home hub. 
• Documentation of a Person-Centered Care Plan, in collaboration with the client and providers
• Review and update of assessments, as mandated by regulations.
• Maintains documentation that is thorough, clearly written, and reflective of members’ plan of care activities.  Documentation needs to be completed at minimum 1x/month and more often as contacts and actions occur in the members’ case and/or as needed for specific program requirements.
• Documents in electronic record regarding care management/coaching activities and termination as appropriate.

Case Review & Collaboration

• Participates as a member of multi-disciplinary Care Management team. 
• Prepare for and participate in case review meetings to share cases, discoveries, concerns and collaborate in the development of plans of action.
• Presents members for review every 90 days or more often, as condition requires.
• Initiates and facilitates member focused meetings to include the member, community providers and significant others, as identified by member for the purpose of care coordination and establishment of a natural support group.
• Participates in inter-agency teams to enhance the work environment and provision of services for members. 
• Participate effectively as a team member within the Monroe Plan team by fostering a positive working relationship with members, providers, and Monroe Plan staff; working effectively with others to coordinate member and access care support services; supporting team members for cross coverage as workload dictates.
• Collaborate with other members of Health Home staff related to member needs, barriers to care and outcome enhancement strategies.
• Manages conflict to support a positive outcome.
• Participate in community activities to promote health and public awareness using Monroe Plan specified materials.
• Assists in locating members in the community through home visits and collaboration with known providers.
• Attend and participate in in-service training.

 
Communication

• Presents in a professional and articulate manner that supports the development of a therapeutic relationship with the member and community providers.
• Provide feedback to providers regarding the progress made and barriers encountered by their patients.
• Demonstrates listening skills to support member engagement and development of a person-centered plan of care.
• Provide program information to members and providers, and other organizations as requested to introduce and support program participation.
•  OTHER FUNCTIONS AND RESPONSIBILITIES
   Performs other duties as assigned.

Requirements

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 Serious Mental Illness, children with SED, developmental disabilities and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting.
• Bachelor'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 2 years 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 Serious Mental Illness, children with SED, developmental disabilities and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting.
•  Credentialed Alcoholism and Substance Abuse Counselor (CASAC) AND 2 years 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 Serious Mental Illness, children with SED, developmental disabilities and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting.
• Bachelor's degree or higher in ANY field with either 3 years 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 Serious Mental Illness, children with SED, developmental disabilities and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting OR 2 years of experience as a Health Home Care Manager serving the SMI or SED population.
• Demonstrates ability to respect individual/family diversity and maintain confidentiality.
• Demonstrates ability to work as a team member.
• Knowledge of and ability to work collaboratively with providers and county/community health and human services.
  Ability to demonstrate excellent communication skills both oral and written as well as strong interpersonal skills.
• Proven ability to work independently and to manage time appropriately.
•  Strong organizational skills.
• Computer literate. Must be able to pass computer documentation competency testing for all software platforms used within the program.  This must occur within 3 months of initial training and/or 6 months of hire, whichever comes first. 
  Candidates will need a NYS driver’s license and to own or have access to reliable transportation that enables them to fulfill travel requirements of the job including but not limited to, daily visits to members’ homes.