The Health Home Plus Care Manager is responsible for Health Home Plus qualified individuals in the following categories: HIV/AIDS, SMI, and Adults. The Case Manager is responsible for case retention activities, including enrolling new clients to maintain a caseload at 15 or as determined by DOH.  Adjustments to case load will be made according to DOH recommendations.  Provide follow-up services according to the standards or care and tracking for their caseload

• Be individually responsible for client retention.
• Maintain full responsibility for caseload including assessments, HARP Eligibility assessments, Care Plans, HML’s, timely documentation; Conduct home visits and fieldwork on an ongoing basis and in accordance with the DOH guidance on minimum standards for Health Home Plus; Conduct diligent search activities for missing clients, Case conference with and obtain necessary records from all primary agencies that are involved with the clients.
• Provide appropriate referrals and ensure follow-up by monitoring the quality of services, verifying and ensuring client participation; Provide education and supportive counseling to ensure that clients understand and follow up with services to which they are referred
• Ensure that ALL needed services are addressed /delivered for each client monthly without limiting services to a single provision of care; services should be prioritized and specific to clients’ needs and not prescriptive.
• Ensure every client on their caseload is CONTACTED AND BILLED FOR each month and provide weekly tracking of billing to their supervisor.
• Document the billable and non-billable services in the required software within 24 hours. Be specific and include comprehensive notes for every service provided.
• Track accurate and up-to-date case lists including closures in a timely manner
• Engage referrals within 24 hours of receipt; Complete enrollments in a timely manner, track, and submit immediately to the Care Manager supervisor assigned
• Participate in the agency quality improvement and professional development programs, attending internal and external training courses and committees 

Administrative Responsibilities: 

• All aspects of the care management process to ensure timely and accurate completion of all care management activities
• Ensure that documentation is completed in a timely manner, including progress notes written within 24 hours.
• Attend weekly care management meetings facilitated by the Care Manager supervisor
• Work with your supervisor to ensure that your caseload is covered when you are out of the office. 

Other Responsibilities: 

• Available for evening and weekend telephone crisis intervention and coverage for other staff as needed
• If bilingual, translate for non-English speaking clients
• Additional duties as assigned

• Master's or bachelor's degree in health, Human Services, Education, Social Work, Mental Health and one year of qualifying experience OR associate's degree in health, Human Services, Social Work, Mental Health, or certification as an R.N. or L.P.N. and two years of qualifying experience; Or a wavier provided through DOH.
• Experience working with HIV/AIDS; mental illness; or those returning to independent living from institutional care; Interest in chronic illnesses, substance abuse and homelessness.
• Awareness of and sensitivity to cultural and socioeconomic characteristics of populations served. Ability to work collaboratively with other professionals.
• Ability to set appropriate limits with clients and co-workers.
• Excellent writing and oral communication skills.
• Good management and organizational skills. Basic computer skills required.
• Able to work 35 hours per week, Monday through Friday during normal business hours, or as to carry out the job responsibilities.