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The Health Home Care Manager is responsible for core services of health home care management including: comprehensive care management, care coordination and health promotion, comprehensive transitional care, youth and family support and referral services and using technology to link services.

Job Responsibilities

• Responsible for comprehensive care management including creating, documenting, executing and updating individualized, patient centered plan of care to integrate continuum of medical, behavioral health services, rehabilitative, long term care and social service needs and clearly identifies the primary care physician/nurse practitioner, specialist(s), behavioral health care provider(s), other providers directly involved in the child’s care.
• Responsible for care coordination and health promotion to engage and retain home health enrollees in care; coordinates and arranges for services; supports adherence to treatment recommendations; monitors and evaluates children’s needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of a plan of care.
• Use Health Information Technology to Input information into health record system to allow for patient’s health information and plan of care to be accessible to multi-disciplinary team of providers including identification of gaps in care including preventive services. Follows-up on tests, treatments, services and referrals.
• Responsible for comprehensive transitional care including providing timely access to follow-up care post discharge which includes at a minimum receipt of a summary care record from discharging entity, medication reconciliation, timely scheduled appointments at recommended outpatient providers, and verification with outpatient provider that patient attended the appointment, and a plan to outreach and re-engage patient in care if appointment was missed.
• Identify available community-based resources and actively manage appropriate referrals, access engagement, follow-up and coordination of services.

Job Requirements

• Bachelor’s degree with 2 years of experience required or Registered Nurse (RN) with 2 years of experience or Master’s degree with 1 year of experience.
• Must be able to work a flexible schedule with variable hours including day, evening, weekend, holiday and subject to call hours.
• Must have a valid driver’s license and reliable vehicle. Travel is required. Ability to coordinate and plan travel for visits and appointments in efficient manner.
• Ability to work with economically and culturally diverse population.
• Skills: communication skills including written, verbal and listening skills.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)