Care Manager provides outreach and enrollment services to individuals presumed to meet eligibility requirements of New York State’s Health Home program. They gather assessments and enter documentation that confirms eligibility and identifies areas requiring supportive services. They work with individuals and service providers to create a comprehensive Plan of Health Care, identify additional service providers as necessary, and coordinate the continuing involvement of individuals and service providers in the execution of the plan. 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. This is a 40 hr/week position (Mon-Fri 8:30 a.m-4:00 p.m.) May require hours outside of these general hours.

• Assesses, engages and enrolls clients into health home program, per NYSDOH and Lead Health Home regulations.
• Complete home visits with enrolled member at least once/month; at a frequency determined by client need.
• Collaboratively complete a yearly assessment of needs, strengths and goals with the member/family and care teams.
• Facilitates yearly (minimum) meetings with member's care teams and works within that team to develop a comprehensive Plan of Care.
• Provide the following core services to enrolled members: care coordination, comprehensive care management, transitional care, crisis intervention and caregiver/family support (coordinating with care team, making referrals to other providers, ensuring follow up from hospital discharges/ED visits, ensures preventive medical/dental care, etc.)
• Document all case activities in an Electronic Health Record, following the NYS guidelines around documentation quality and time frames.
• Ensure that monthly billing standards are met for each enrolled member and that a billing questionnaire is submitted within the month that the activity took place.
• Participate in mandatory and optional trainings.
• Participate in weekly supervision.
• Other duties as assigned.

Other Duties: Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice due to business needs.

• Bachelor’s Degree with two years of experience; master’s degree with one year of experience preferred.
• Relevant experience in serving children and families in child welfare, developmental disabilities, behavioral health, primary health care, or social services.
• Experience coordinating and participating in team settings.
• Solid writing and verbal communication.
• Work effectively and knowledgeably across a broad spectrum of cultural, ethnic, and racial communities.
• Ability to work in an effective and focused manner when self-directed and beyond immediate oversight.
• Ability to deliver family-driven, youth-guided services.
• Requires computer proficiency including word processing skills and the ability to provide culturally competent practice.
• Must have valid driver’s license that meets The Salvation Army insurance requirements.
• Must have access to a vehicle to provide home visits.