- Persistent and assertive outreach and engagement using strength-based approaches beginning either at known "hang-outs" or "hot spots" within the local communities or during an inpatient hospital admission or emergency department visit.
- Continuously assess the health and social needs of participants through SOS's conversational and observational assessments and formalized risk assessment tools for those identified as being at high risk.
- Participate in hospital discharge planning meetings to identify the best community resources for returning members.
- Assist with appointment navigation including accompaniment to appointments, transportation training, reengagement in community care, and addressing barriers to care.
- Review documentation and conduct comprehensive psychosocial assessments to determine the medical, psychiatric, housing, and other social needs of the member within the community.
- Obtain historical and collateral information from multiple sources to support members behavioral and physical health needs.
- Monitor, evaluate, and record participants progress with respect to care plan goals.
- Adheres to Monroe Plan professional boundaries and protocols.
- Work in collaboration with the regional partners to identify available housing and to support participants through the process. Tasks may include applying for housing, prepping for interviews, follow up with housing providers, and assistance with moving in (day of move) and with obtaining housing supplies and learning about the neighborhood.
- Participate in hospital discharge planning meetings to identify the best community resources for returning members.
- Once housed, work with members and their housing providers to resolve clinical issues that are impacting the member's ability to manage and retain supportive housing.
- Foster relationships with community providers to ensure that members are connected with appropriate services as they transition back into the community. Document a Person-Centered Care Plan, in collaboration with the client and providers
- Collect and report data, as required and work with team leader and other SOS staff to use data to inform future care delivery.
- Adhere to program documentation requirements in the Electronic Health Record.
- Provide program information to members and providers, and other organizations as requested to introduce and support program participation.
- Presents in a professional and articulate manner that supports the development of a therapeutic relationship with the member and community providers.
- Provide feedback to providers regarding the progress made and barriers encountered by their members.
- Demonstrates listening skills to support member engagement and development of a person-centered plan of care.
- Performs other duties as assigned.
- Attend and participate in team meetings and supervisory sessions.
- Cannot perform any tasks which are governed by license or registration (i.e. cannot answer questions or make recommendations RE diagnosis, medications or treatment).
- Cannot transport active Monroe Plan members at any time.
- Cannot perform hands on care.
- Bachelor's degree or higher in Psychology, Social Work, Sociology, or related field.
- Minimum of two years of previous care management experience, working with the Medicaid population.
- Minimum of two years' experience in providing advocacy services to people who are mentally ill and/or homeless.
- Knowledge of homeless resources, shelter systems and transportation systems.
- Knowledge of counseling principles and methods for mental illness and substance use disorders.
- Knowledge of treatment, rehabilitation, and community support programs as they relate to recipient/residents, families, and staff.
- Ability to develop, evaluate, implement, and modify treatment intervention to meet the needs of individual recipients.
- Ability to prepare accurate and timely reports.
- Demonstrates ability to respect individual/family diversity and maintain confidentiality.
- Demonstrates ability to work as a team member.
- Knowledge of and ability to work collaboratively with providers and county/community health and human services.
- Ability to demonstrate excellent communication skills both oral and written as well as strong interpersonal skills.
- Proven ability to work independently and to manage time appropriately.
- Strong organizational skills.
- Computer literate. Must be able to pass computer documentation competency testing for all software platforms used within the program.
- Candidates will need a NYS driver's license and to own or have access to reliable transportation that enables them to fulfill travel requirements of the job including but not limited to, daily visits to members' homes.
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Care Manager - Bath, United States - Monroe Plan for Medical Care
4 weeks ago
Description
Looking for meaningful work with an Organization that values you? It's here
Monroe Plan for Medical Care is hiring in Steuben County Join our team of dedicated, caring professionals in our passionate pursuit of improved access and quality of healthcare for underserved populations.
For over 50 years, Monroe Plan for Medical Care, a not-for-profit health care services organization, has been focused on improving the health status of individuals and families who are recipients of government sponsored health insurance. Monroe Plan is the largest Care Management Agencies serving 28 counties and over 3000 members with an outstanding reputation for excellence throughout our service area
We've earned that reputation by providing quality care management focused on compassion, empowerment, and teamwork. Our award-winning work culture is built on these same principles When you join our team, you can expect to reap the intrinsic rewards of serving others while enjoying flexible work arrangements, competitive pay, superior benefits, and a supportive, inclusive culture
Candidate must be willing to travel throughout Steuben County on a regular basis.
Grade 207: This is a full time position, working from home.
The minimum and maximum annual salary that Monroe Plan believes in good faith to be accurate for this position at the time of this posting are $46,948 - $57,380. In addition to your salary, Monroe Plan offers a comprehensive benefits package (all benefits are subject to eligibility requirements) and non-monetary perks. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
POSITION SUMMARY
The Care Manager's role will involve community outreach on the streets, coordinating members' needs before and after their move from street to home, enhancing their daily living skills, accompaniment to appointments, and advocating on their behalf when faced with discrimination or healthcare inequities. Member choice, harm reduction, non-coercion, flexibility, and person-centered care are essential elements of the SOS program model and should be front and center of the care delivered by the Care Manager.
This position works with substantial independence in the field, with consultation available from Team Lead, as needed.
ESSENTIAL JOB DUTIES/FUNCTIONS
% of Time
Essential Function
50%
Outreach and Engagement
Member/Provider Collaboration
Reporting
Communication
OTHER FUNCTIONS AND RESPONSIBILITIES
PHI MINIMUM NECESSARY USE: This staff position PHI access will be determined based on Minimum Necessary standards. The Minimum Necessary Grid can be found on the Human Resources and Compliance Web pages.
This job description is only a summary of the typical functions of the job, not an exhaustive or comprehensive list of all possible job responsibilities, tasks and duties. Additional responsibilities, tasks and duties may be assigned as necessary.
Monroe Plan for Medical Care is an Equal Opportunity Employer