Health Home Plus Care Manager

Position Summary

The Health Home Plus Care Manager partners with individuals living with mental illness, substance use disorders, and physical health challenges to provide comprehensive care management. Core responsibilities include care coordination, health promotion, transitional care, patient and family support, referrals to community resources, and the use of health information technology. The goal is to help individuals improve their health and wellness, live self-directed lives, and work toward their full potential.

Responsibilities

Direct Care & Client Services

• Provide the six core Health Home services: Comprehensive Care Management, Care Coordination, Health Promotion, Comprehensive Transitional Care, Patient and Family Support, and Referral to Community and Social Supports.
• Engage and retain individuals who may be disconnected from care or who have complex needs, including those with histories of homelessness, criminal justice involvement, first-episode psychosis, or transitional-age youth.
• Utilize evidence-based practices such as motivational interviewing, suicide-prevention strategies, trauma-informed care, risk screening, and person-centered planning.
• Maintain a caseload of up to 20 individuals meeting Health Home Plus criteria.
• Conduct comprehensive assessments, screenings, outreach, and engagement activities.
• Arrange for additional assessments when needed (e.g., substance use, mental health risk, abuse/neglect, domestic violence).
• Navigate the healthcare system effectively, including referrals to housing supports, crisis services, peer support, and other community resources.
• Support individuals through coordination of care, advocacy, recovery support, and trauma-informed practices.
• Develop, revise, and monitor person-centered Plans of Care in accordance with Health Home and Managed Care Organization requirements.
• Facilitate effective transitions of care by collaborating with hospitals, treatment providers, and Managed Care Organizations.
• Engage family members, natural supports, and service providers in the care coordination process.

Documentation & Compliance

• Complete accurate, timely documentation in accordance with organizational, county, Medicaid, Health Home, and OMH regulations.
• Maintain secure, confidential handling of protected health information in compliance with HIPAA.
• Provide each client with a minimum of four Health Home core services per month, including face-to-face, home-based, and/or telephonic contacts.

Management Responsibilities

• Maintain organized and accurate case records, reports, and required documentation.
• Ensure service quality, continuity of care, and adherence to all program standards.
• Participate in scheduled individual supervision (weekly to bi-weekly), monthly clinical supervision, required trainings, and meetings.
• Participate in on-call rotation as assigned.
• Coordinate services among internal and external providers to ensure integrated care.
• Communicate effectively with supervisors, team members, and service partners.
• Model person-centered, recovery-oriented, culturally competent care.
• Promote collaborative relationships with community partners, providers, and internal teams.
• Demonstrate initiative, problem-solving, adaptability, and commitment to continuous improvement.
• Contribute to case conferences, interdisciplinary discussions, and clinical reviews.
• Participate in and support a trauma-informed, recovery-oriented organizational culture.

Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.

Other duties as assigned

•  Follows all applicable policies, federal and state laws, and East House compliance standards.
• Collaborates with the Office of Ethics, Compliance & Quality to address non-compliance, and document corrective actions. 

Note: This job description may not cover all job duties and is subject to change without notice. Job duties, responsibilities, and/or activities may change at any time with or without notice.

Qualifications

Required Education & Experience

• Master’s  degree in a  qualifying field and one (1) year of experience; OR
• Bachelor’s  degree in a qualifying field and two (2) years of experience; OR
• Bachelor’s degree or higher in any field with either:
• Three (3)  years of qualifying experience, OR
• Two (2) years of experience as a Health Home Care Manager serving SMI or SED populations.
• Staff who meet State Waiver qualifications are eligible.
• Valid NYS Driver’s License (driving is an essential function).

Preferred Skills & Abilities

• Experience working with culturally diverse individuals with mental health and/or substance use needs.
• Skills in counseling, crisis assessment and intervention, person-centered planning, and recovery-oriented practices.
• Strong communication, collaboration, and interpersonal skills.
• Ability to assess, monitor, and evaluate client needs and progress.
• Effective time management and ability to update electronic records in real time.
• Computer proficiency, including email, Microsoft Word, and basic use of databases and spreadsheets.

 Competencies

•  Accountability
• Communication
•  Conflict   Resolution
•  Effective Documentation
•  Flexibility
• Initiative
• Stress Management
•  Teamwork

Working Conditions/Work Environment

• Work   performed in traditional office and home-based environments.
• Occasional   pressure related to time demands.
• Local   travel required; frequent transportation of clients.
•  Must   be able to work on-call rotations, weekends, and some evenings.
• Ability   to report to the office at least once weekly or as requested.

Physical Demands

• Frequent   sitting, computer work, documentation, and verbal/written communication.
• Occasional   lifting up to 30 lbs., walking, standing, and reaching.
• Adequate   vision and hearing to perform essential job functions.
• Ability   to navigate client homes, which may not be handicap accessible.
• Ability   to maintain emotional stability during stressful situations.

EEO Statement

East House encourages diversity in the workplace; we are an Equal Opportunity Employer.

Minority/Female/Sexual Orientation/Gender Identity or Expression/Veteran/Disability