- Provide direct coaching, education and advocacy in linking, engaging and retaining clients in services identified in the Plan of Care.
- Escort clients to appointments and provide and gather critical information, both in the field and in the office, with the goal of health and wellness promotion and a reduction in preventable negative health or social events.
- Elicit the support of all providers involved in a client's care and ensure maximized communication among all parties via face-to-face contacts, phone calls, emails, case conferences, etc.
- Conduct vigorous outreach in identifying and locating potential clients either referred through the community or by the lead Health Home.
- Provide intensive care management services to clients living with chronic illnesses and their families/support systems and advocate aggressively for clients to obtain the full range of needed services and ensures coordination of these services.
- Ensures the timely completion of internal and external required assessments (Comprehensive Assessments, CANS-NY assessments, Eligibility and Appropriateness Assessment, etc).
- Ensures the timely completion of the initial Plan of Care and plan reviews based on Lead Health Home policy.
- Ensures the Plan of Care for each enrolled member includes quality SMART goals, interventions and targets.
- Completes progress notes in accordance with Health Home and departmental policies.
- Responsible for the overall chart compliance of assigned caseload members.
- Demonstrate the ability to clearly articulate, verbally and in writing, the aims and goals of the Health Home program and the process to potential clients and community members and Acacia Network staff.
- Responsible for coordinating and attending provider case conferences.
- Participate in quality improvement activities, projects and reviews.
- Complete periodic requests for narrative or quantitative data reports for program review.
- Identify new sources of potential clients and conduct outreach presentations as requested.
- Meet regularly with supervisor and attend staff meetings. Be prepared to discuss care management and operational issues impacting performance and program operations.
- Complete and submit daily activity log in accordance with departmental policies.
- Maintain and update caseload tracking tool.
- Escort clients to entitlement offices to gain, maintain or regain eligibility; Verify client eligibility through ePaces, as requested.
- Conduct outreach in accordance with Health Home policy via phone, letter, and field work to client/collateral/provider/ support system to engage clients or strengthen connectivity.
- Conduct home visits on a monthly basis to members on caseload as needed to provide comprehensive care management services.
- Provide Diligent and Continued Search efforts in order to regain and maintain member engagement.
- Provide member referrals to Health Navigator and Outreach team via member referral to HHSA and HHSC.
- Attend supervision with Children Care Management Supervisor as scheduled and be prepared to discuss topics around caseload, engagement, work related concerns, barriers, trainings, etc.
- Assess and respond per agency guidelines to client complaints or grievances.
- Help maintain health and wellness and prevent secondary disease complications.
- Ensure community-follow up to engage the client in care; promotes compliance with medical appointments and encourages client self-sufficiency and empowerment.
- Coordinate schedule and appointments with Health Navigator to ensure client attendance at appointments or engage in outreach efforts.
- Organize fieldwork to maximize delivery of service to clients.
- Utilize company issued cell phone to stay in contact with members/ providers/ Health Home team on a 24 hour basis.
- Coordinate, communicate and support members within serviced boroughs.
- Coordinate and orchestrate IDT meetings between member, legal guardian/ parent, providers, ACS etc.
- Link at-risk youth to services and programs that support that support functioning in the least restrictive community setting.
- Bachelor's Degree required.
- Bachelor's Degree in one of the following fields is required: social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services fields preferred.
- Two (2) years' experiences in successful community outreach/recruitment or volunteer coordination preferred.
- Must obtain Mandated reporter (2 hours) prior to hire date. Website info:
- Excellent public speaking and presentation skills.
- Ability to communicate effectively orally and in writing.
- Ability to connect with others and forge strong relationships.
- Highly organized, motivated self-starter. Excellent time management skills.
- Ability to organize and maintain detailed records; complete necessary paperwork and meet deadlines.
- General knowledge of organization, community and/or social service resources and programs.
- Bilingual - Spanish speaking a plus.
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Description
Job Description
Job DescriptionJob descriptionAcacia Network, the leading Latino integrated care nonprofit in the nation, offers the community, from children to seniors, a pathway to behavioral and primary healthcare, housing, and empowerment. We are visionary leaders transforming the triple aim of high quality, great experience at a lower cost. Acacia champions a collaborative environment to deliver vital health, housing and community building services, work we have been doing since 1969. By hiring talented individuals like you, we've been able to expand quickly, with offices in Albany, Buffalo, Syracuse, Orlando, Tennessee, Maryland and Puerto Rico.
The Care Manager for Children's Health Home provides patients advocacy, outreach, education, and care management. Skills and competencies required for the position include communication, cultural competence, training professional experiences, and education. The activities are tailored to meet the unique needs of the communities. The Care Manager for Children's health home works closely to collaborate services to link at-risk youth to services and programs that support that support functioning in the least restrictive community setting. The Care Manager works to provide stability for at-risk youth who are chronically ill, underserved, mentally disable, and high inpatient and emergency department utilizers. This position includes no managerial or supervisory responsibilities.
KEY ESSENTIAL FUNCTIONS:
REQUIREMENTS:
