Job Title: Bilingual Heath Home Care Manager
Location: Rochester, NY, Monroe County
Reports to: Program Director
Department: Behavioral Health Services
Employment Type: Full Time, Monday – Friday Hours: 8:30am – 5:00pm
The health home care manager provides care coordination services to clients with complex chronic conditions; conditions may include mental illness, social and medical needs. The care manager is expected to promote independence by assisting clients with understanding and navigating the medical, behavioral, and social services systems through the completion of assessments, crisis plans and plan of care. The care manager will engage the clients in a person-centered approach to link clients to necessary supports in the community, including member family support, providers, and peer services. Ongoing collaboration with community partners, providers and supports systems is essential to ensure best health care outcomes.
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 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 adjusts as necessary. Provides advocacy and empowers clients in developing self-advocacy and sufficiency skills.
- 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
- Maintain follow up with clients post discharge facilitate care coordination with primary care and/or specify care Engage individuals and their family/care givers/ supports in the client’s treatment.
- Address overall health care 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. Promote preventative care appropriate to clients’ age, gender, and diagnosis.
- Advocate and refer to emergency social support services (e., housing, food, access to medical/ mental) 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 as necessary as needed, including after hours and on
- Support the implementation of quality improvement measures for the care management Participate actively in team meeting and supervision to enhance in professional development. Maintain excellent record keeping.
Associate degree in human service field with 4 years of experience; or Bachelor’s degree in health and human services preferred and minimum of 2 years of qualifying experience; Master’s degree in related field with one year of experience. Work history and education to include case management or casework with individuals who have chronic illness, mental illness, chemical dependency, developmental disability, homelessness, crisis intervention, etc.
- Computer proficiency is Must have excellent organizational and time management skills.
- Must have NYS Driver’s License with no major violations within the last 5 years
- Must pass criminal background check through the justice center, criminal history does not preclude eligibility