Health Homes Care Manager

Engages and assesses HH clients with the goal of coordinating care, and utilizing a shared care plan in which the client’s needs are accurately expressed. Completes documentation in a clear and comprehensive manner which is in compliance with DOH, Health Home and Agency standards and requirements for quality care and billing. Coordinates with pertinent service providers to ensure that all clients’ needs are being addressed. Provides proactive care management, evidenced through provision of core services and development of a care plan which leads toward client centered outcomes. Utilizes electronic health records to effectively coordinate care for the client.

Description of

Duties: Engage new HH clients into service and maintain engagement in care coordination. Conduct intake and comprehensive health assessments/reassessments, identifying mental health, chemical dependency and social service needs. Develop comprehensive, measurable, goal-oriented care plans in collaboration with interdisciplinary team of external providers. The care plans must clearly identify and integrate the entire continuum of care, addressing all needs identified by the comprehensive assessment. Advocate and assist clients in obtaining and maintaining entitlements and housing. Assist and support clients in treatment adherence recommendations, including prevention, wellness, recovery, and care transitions. Refer and follow-up on referrals for clients to ensure medical stabilization. Closely coordinate all hospital discharges with hospital or acute care settings to ensure thorough implementation of the discharge plan, and follow-up on recommendations from the ER, hospital or acute care facility. Assist clients and their families in resolving barriers to obtaining medical services. Escort clients to appointments when necessary to increase medical adherence. Conduct home and field visits. Maintain on-going contact with interdisciplinary team of medical providers, acting as team leader for the client’s care coordination activities. Provide crisis intervention when required. Meet and maintain program productivity standards. Maintain Electronic Health Record and all required electronic data. Track and maintain a system of patient medical appointments, labs and other critical time-sensitive activities required to maintain the client’s health. Complete all program standards documentation as required. Participate in supervision and program review each week. Attend and participate in monthly department, All Staff and other required meetings. Be familiar with Cornerstone policies and procedures and the Employee Handbook. Maintain confidentiality of all aspects of Cornerstone including, but not limited to, patient confidentiality, financials, and employee relations. Perform other related duties as assigned