585-325-4910 info@badenstreet.org

Department: Behavioral Health Services

Location: Rochester, NY; Monroe County

Job Title: Health Home Care Manager/Bilingual Care Manger

Reports to: Program Supervisor/Program Director

Employment Type: Full Time   Hours: 8:30a-5pm

General Description: 

The Health Home Care Manager provides care coordination services to members of the HHUNY Health Home program with complex chronic conditions; conditions may include mental illness, social and medical needs.   


• The Care Manager must demonstrate proficiency in the following Health Home core competencies:

• Provide comprehensive care management services to patients who meet the program criteria. Coordinates outreach and engagement activities on locating, connecting and retaining clients in care management services. Assesses the needs, strengths and goals of the client to create a plan of care based on the clients’ desired outcomes. The care manager facilitates the development and implementation of the plan of care utilizing Patient Centered Practices and makes adjustments as necessary. Provides advocacy and empowers clients in developing self-advocacy and sufficiency skills.

• Completes appropriate assessments.

• Provides comprehensive transitional care from inpatient back into the community with emphasis on care coordination, services for post- critical events (i.e. Emergency room visits, inpatient admissions/discharges). Guide clients through smooth transitions between levels of care by linking clients with community support, resources and referrals to ensure needs are met.

• Maintain follow up with clients post discharge from a hospital, facilitate care coordination with primary care and/or specialty care providers. Engage individuals and their family/care givers/ supports in the client’s treatment.

• Address overall health care needs. Encourage appropriate use of Emergency rooms, urgent care and on call medical triage services. Advocate on the client behalf for services and assist as necessary with scheduling appointments and transportation.

• Advocate and refer to emergency social support services (I.e. housing, food, access to medical/mental health services) as needed. Assist clients with creating a proactive individualized plan to avoid future crisis situations.

• Support client in the community as needed through home visits, client transportation, attending provider and community based organization appointments.

• Provide crisis intervention and assist client in crisis planning.

• Support the implementation of quality improvement measures for the care management program. Participate actively in team meeting and supervision to enhance in professional development. Maintain excellent record keeping.

Minimal Qualifications:

• Computer proficiency is required. Must have excellent organizational and time management skills • Must have NYS Driver’s License with no major violations within the last 5 years and proof of automobile insurance. • Must pass criminal background check through the justice center, criminal history does not preclude eligibility.


• Associates degree in a human service field with a minimum of 2 years of experience working in health and or community services

• Bachelor’s degree in any of the following: child & family studies, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreational therapy, rehabilitation, social work, sociology, or speech and hearing; Preferred

Please forward resume and cover letter to:

Attn:  Mary Gomez DeSantis, LMSW- Director of Behavioral Health & Community Services

Email: mgomez@badenstreet.org

Tel: (585) 445-6754