Full Time 40 hours Grade 053 Psych SMH Long Term Care Schedule 8 AM-4:30 PM; WKENDS AS NEEDED WITH ON-CALL Responsibilities General Description: The Care Manager provides professional Comprehensive Care Management services to patients assigned to the Strong Behavioral Health Care Management Program, after patient enrollment into a NYS-licensed Health Home. The Care Manager is responsible for development and management of each enrolleeâ™s care plan which includes and addresses medical, behavioral health and social service needs and goals. Working with other Care Managers in a team structure, a Care Manager collaborates with a broad array of medical health, behavioral health and social service providers, as well as enrollees and their families. Patients enrolled into the Health Home Care Management program have been identified as acutely complex individuals, typically high utilizers of costly services who are also at significant clinical risk due to underutilization of outpatient services. The Care Manager subscribes to the Department philosophy of creating a culturally competent environment by treating patient, families, trainees, and co-workers in a sensitive manner with appropriate attention to cultural differences. Specific Responsibilities: Under direction and with considerable independence, provides complex care management services consistent with NYS Regulations and Policy for the provision of Health Home services. Responsibilities include all, or most of the following, as well as related duties. The Care Manager provides outreach and engagement activities focused on finding, connecting and retaining enrollees in Health Home care management services. The Care Manager completes comprehensive care needs assessments for assigned Health Home enrollees that include a delineation of medical/behavioral health and social service needs. The Care Manager develops a Comprehensive Health Home Care Plan using person centered practices for assigned enrollees; Care Manager develops care plan with each individual enrollee, either in person or telephonically, focusing on linking the individual to needed clinical and social services. Care Manager engages enrollee in ongoing discussion of care plan, identifying barriers to success, goals met, progress, set-backs and implements updates or changes into care plan as needed. The Care Manager interacts with a variety of community providers and resources to obtain needed services and supports for enrolled patients. Community and family resources are also accessed and utilized to create sustainable support systems.Reviews and discusses plan with each enrollee focusing on linking individuals to clinical and social services with system and community providers. The Care Manager completes a periodic review of Comprehensive Service Plans as prescribed by Health Home Regulation.Assists in the collection of information for reporting of services to Health Homes and NYS DOH.Assists with record reviews and NCQA quality initiatives. The Care Manager monitors assigned enrolleesâ™ utilization of services, ensuring that care is accessible, attended and effective. The Care Manager monitors the use of costly Emergency and Inpatient services, supporting enrollees in keeping all aftercare appointments and addressing barriers as necessary. The Care Manager monitors and encourages enrollees to follow treatment recommendations. Barriers to care are identified and addressed in conjunction with the enrollee, service providers and community supports. The Care Manager interacts with a variety of community providers and resources to obtain needed services and supports for enrolled patients. Community and family resources are also accessed and utilized to create sustainable support systems. The Care Manager documents services provided into the Care Management Electronic Record, in compliance with hospital policy and Health Home regulations. Care Manager also ensures that all providers of enrolleeâ™s treatment team are identified within the electronic record. The Care Manager participates in on-call activities as directed by program leadership. The Care Manager participates in regularly scheduled team meetings as prescribed by department policy. The Care Manager maintains expected productivity standards as prescribed by department policy. The Care Manager participates in available cultural competency events and training appropriate to job duties. Qualifications Bachelorâ™s Degree in an appropriate human services field and minimum 4 years direct experience working with individuals diagnosed with Serious Mental Illness (SMI) or an equivalent combination of education and experience. Knowledge and experience with physical health care issues and substance abuse issues common to the enrolled population is desired. Must possess a valid NYS Driverâ™s License, have and maintain a satisfactory driving record.
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