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 case load 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
· All aspects of the care management process in order 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.
· 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 Degree in health or human services related field and 2 years of experience or a Bachelor’s Degree in health or human services related field and 4 years’ 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 needed to carry out the job responsibilities.