Position Type/Expected Hours of Work: 40 hours weekly. Flexible to the needs of the program.

Qualifications: A Bachelors of Arts/Science degree with 2 years relevant experience, OR NYS licensure and registration as a Registered Nurse, OR A Masters degree with one year relevant experience Must have strong written, verbal and organizational skills. Computer skills necessary. Travels within tri-county frequently.

Work Authorization/Security Clearance: Authorized to work in the United States and pass all background clearances.

Summary/Objective: The Care Manager conducts and schedules assessments, referrals, advocacy and supports, counseling, education of patients and enrollees and care team members assuring the patient receives quality services to maintain optimum healthcare needs without barriers. Outreach and engagement to formally enroll referred individuals into the care management program. Conduct assessments, evaluates needs, establishes and maintains care plan and maintains referrals for enrollees. Assures supports are in place inclusive of peer and family contacts.

Essential Functions: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions:

• Develops Interim Plan of Care based on preliminary clinical information and assigned level that will identify linkages and services immediately required, based on information received from referral sources if applicable.
• Ensures all initial linkages are established and maintained.
• Collaborates with all service providers and establishes team communication plan.
• Monitor goals on a continuing basis and that team is communicating.
• Monitors that care plan is relevant to health home policies and procedures.
• Consults with family members and social supports to maintain support consistency.
• Advocates for additional services and linkages as appropriate.
• Maintains current care management documentation and information regarding care management activities within the required health information technology (HIT) system.
• Enter and maintain progress notes as it pertains to the Plan of Care.
• Attend Quarterly Regional meetings for the CNYHHN.
• Participate in monthly conference calls with CNYHHN providers.
• Will engage families in the outreach process once a referral is received to the agency.
• Will ensure compliance with the Central New York Health Home Network (CNYHHN) policies and procedures.
• Will attend all required online and in-person training required by (CNYHHN) and agency.
• Participate with agency committee(s) as assigned.
• Attend and satisfactorily complete all required in-services.

Competencies:

• Ethical Conduct.
• Time Management.
• Organization Skills.
• Project Management.
• Personal Effectiveness/Credibility.

Work Environment: This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; lift; use hands to finger, handle or feel; and reach with hands and arms.

Other Duties: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice. I have read and received a copy of the above job description and understand the responsibilities fully. I understand that the preceding job description will be reviewed/updated at least annually; more frequent updates will depend on contract needs.