The Care Manager provides outreach and enrollment services to children presumed to meet eligibility requirements of NY State’s Children’s Health Home Program.  Gathers assessments and enters documentation that confirms eligibility and identifies areas requiring supportive services.  The Care Manager works with children, families, and service providers to create a comprehensive Plan of Health Care, identify additional service providers as necessary and coordinate the continuing involvement of families and service providers in the execution of the plan.  The Care Manager documents progress and arranges for eventual transition between health homes as necessary, or from health homes to other levels of service, following changes in eligibility.

1. Document all case activity, including outreach, consent development and assessment, plan development, client progress and transition arrangements.
2. Responsible for a caseload of 12 children.
3. Responsible for actively pursuing referrals for the program.
4. Administer CANS-NY, updating periodically.
5. Develop a comprehensive, family driven youth-guided Plan of Health Care.
6. Inventory and coordinate existing services relevant to the Plan of Care, identifying and securing additional services as appropriate.
7. Convene and conduct quarterly meetings to review progress, update POC’s and confirm continuing client eligibility.
8. Provide education to family and child concerning the nature and desired effect of services, along with information concerning conditions being treated.
9. Assist families and children in the acquisition and maintenance of public benefits (e.g., financial, educational, social and community services).
10. Provide Health Home services for children with high acuity needs, including at least two services per month, with at least one of those conducted face to face.
11. Assure responsible transition of client service into and out of Health Home care, between child and adult health homes and between inpatient and community care, as appropriate.
12. Participate in mandatory and optional training.
13. Other duties as needed