585-325-4910 info@badenstreet.org

Job Title: Health Home Plus Care Manager/Bilingual
Location: Rochester, NY, Monroe County

Reports to: Program Coordinator
Department: Behavioral Health Services

Employment Type: Full Time, Monday – Friday, 8:30am – 5:00pm



Health Home Plus care management services provides care to a specialized population with a diagnosis of Severe Mental Illness, HIV AIDS, Substance Use Disorders, post incarceration etc.

The Health Home Plus 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 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.
  • 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 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. Promote preventative care appropriate to clients’ age, gender and diagnosis.
  • Advocate and refer to emergency social support services (I.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 call.
  • 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:

HH+ shall always be delivered by a CMA with staff who have the education and experience appropriate to serve the high-need, behavioral health population under appropriate supervision. The following Minimum Qualifications to apply:

Education and Experience

  1. A Master’s degree in one of the qualifying fields and one (1) year of Experience;


  1. A Bachelor’s degree in one of the qualifying fields and two (2) years of Experience;


  1. A Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and two (2) years of Experience;


  1. A Bachelor’s degree or higher in ANY field with either: three (3) years of Experience, or two (2) years of experience as a Health Home care manager serving the SMI or SED population.

Experience shall consist of: 1. Providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse, and/or children with SED; OR 2. Linking individuals with Serious Mental Illness, children with SED, developmental disabilities, and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services). Supervision shall be provided by staff meeting either of the following qualifications:

In addition:

  • 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
  • Must pass criminal background check through the justice center, criminal history does not preclude eligibility
  • Fluency in Spanish- preferred


Baden Street Settlement or Rochester is an equal opportunity employer

Please send resumes to:

Mary DeSantis

Tel: 585-5446754 or Fax: 585-246-3878