Health Home Care Manager

A Plus Early Intervention is currently hiring Care Manager for the Health Homes Program in New York City. The Care Manager will be responsible for the services for children and their families.

• Enrollment and Consent:

1. Obtain required Care Management enrollment consent from the individual or legal guardian.

• Needs Assessment:

1. Complete initial and ongoing needs assessments (Child and Adolescent Needs and Strengths; CANS) to determine the individual’s most appropriate level of care management.
2. Complete the Mandated Reporter Training

• Individualized Plan of Care (IPC):

1. Responsible for the overall management of the patient’s IPC.
2. Coordinate the enrollee’s provision of services per their acuity level.
3. Support adherence to treatment recommendations.
4. Monitor and evaluate a patient’s needs, including:
5. Prevention
6. Wellness
7. Medical and mental health care
8. Care transitions
9. Social and community services

• Client Contact and Visits:

1. Meet client contact requirements:
2. Caseloads may be “blended with High, Medium, and Low.” Ranging from 21-30+ cases
3. Care Coordinators serving children must have face-to-face visits on a consistent

schedule based on acuity level (high, medium, or low) per DOH rules (1x a month for Medium/High and every 60 days for Low)

• Documentation:

1. Meet Care Management documentation requirements timely and accurately using designated Care Management Portals (MAPP, EHR, and HSC).
2. Care management notes must be in the system within 72 hours or earlier of visit/encounter

• Advocacy and Support:

1. Advocate for clients within the agency and with external service providers.
2. Promote wellness and prevention by linking enrollees with resources and services based on individual needs and preferences.
3. Educate the child/caregiver on chronic condition care, immunizations, screenings, and other preventive interventions.
4. Assist clients in obtaining and maintaining public benefits necessary for health care services, including:

• Medicaid
• Cash assistance eligibility
• Social Security
• SNAP
• Housing
• Legal services
• Employment and training support

• Communication:

1. Effectively communicate and share information with the individual, their families, and other caregivers, considering language, literacy, and cultural preferences.

• Care Planning and Coordination:

1. Conduct care planning meetings/conferences and serve as an interdisciplinary team member to provide/coordinate comprehensive and holistic care.
2. Identify available community-based resources and manage appropriate referrals, access, engagement, follow-up, and coordination of services.

• Hospital and ER Admissions:

1. For hospital admissions, engage in the discharge planning process to ensure recommended post-discharge services are in place.
2. For ER admissions, meet with members in the Emergency Room as per Health Home mandates.

• Staff Development:

1. Attending and participating in ongoing staff development training to enhance skills needed for the Care Coordinator position.

• Additional Responsibilities:

1. Ensure periodic evaluations and follow-up treatments for dental, vision, and hearing care per Medicaid guidelines.
2. Perform other duties as assigned.

• Physical Requirements:

1. While performing the duties for this job, the employee is regularly required to communicate clearly and effectively. The employee is required to stand, use mobility, handle, feel, and reach. The employee is occasionally required to climb stairs, sit and stoop, kneel or crouch. The employee may occasionally lift and/or move up to 25 pounds

• Qualifications for Care Manager:

1. Education and Credentials: Bachelor’s Degree Required: Social Work or a related field.
2. Preferred: Bilingual Spanish-speaking candidates are highly encouraged to apply.

• Experience Requirements for High Acuity Members: Relevant Positions:

1. Case Planner Care Coordinator Case Manager Case Worker in a social service setting Specific Areas of Experience: Child Welfare ACS (Administration for Children's Services) Foster Care
2. Expertise and Experience: Serving children and families in child welfare, developmental disabilities, mental health, healthcare, or other systems. Providing preventive services.
3. Additional Requirements for High Acuity Enrollees: Demonstrated knowledge and understanding of the needs of high-acuity children and their families. Evidenced by additional years of experience, education, or training.
4. Experience with Medical Fragility: Extensive experience in coordinating care for children with medical fragility.
5. Service Coordination Skills: Providing service coordination. Information, linkages, and referrals for community-based services.

A Plus Early Intervention is currently hiring Care Manager for the Health Homes Program in New York City. The Care Manager will be responsible for the services for children and their families.

• Enrollment and Consent:

1. Obtain required Care Management enrollment consent from the individual or legal guardian.

• Needs Assessment:

1. Complete initial and ongoing needs assessments (Child and Adolescent Needs and Strengths; CANS) to determine the individual’s most appropriate level of care management.
2. Complete the Mandated Reporter Training

• Individualized Plan of Care (IPC):

1. Responsible for the overall management of the patient’s IPC.
2. Coordinate the enrollee’s provision of services per their acuity level.
3. Support adherence to treatment recommendations.
4. Monitor and evaluate a patient’s needs, including:
5. Prevention
6. Wellness
7. Medical and mental health care
8. Care transitions
9. Social and community services

• Client Contact and Visits:

1. Meet client contact requirements:
2. Caseloads may be “blended with High, Medium, and Low.” Ranging from 21-30+ cases
3. Care Coordinators serving children must have face-to-face visits on a consistent

schedule based on acuity level (high, medium, or low) per DOH rules (1x a month for Medium/High and every 60 days for Low)

• Documentation:

1. Meet Care Management documentation requirements timely and accurately using designated Care Management Portals (MAPP, EHR, and HSC).
2. Care management notes must be in the system within 72 hours or earlier of visit/encounter

• Advocacy and Support:

1. Advocate for clients within the agency and with external service providers.
2. Promote wellness and prevention by linking enrollees with resources and services based on individual needs and preferences.
3. Educate the child/caregiver on chronic condition care, immunizations, screenings, and other preventive interventions.
4. Assist clients in obtaining and maintaining public benefits necessary for health care services, including:

• Medicaid
• Cash assistance eligibility
• Social Security
• SNAP
• Housing
• Legal services
• Employment and training support

• Communication:

1. Effectively communicate and share information with the individual, their families, and other caregivers, considering language, literacy, and cultural preferences.

• Care Planning and Coordination:

1. Conduct care planning meetings/conferences and serve as an interdisciplinary team member to provide/coordinate comprehensive and holistic care.
2. Identify available community-based resources and manage appropriate referrals, access, engagement, follow-up, and coordination of services.

• Hospital and ER Admissions:

1. For hospital admissions, engage in the discharge planning process to ensure recommended post-discharge services are in place.
2. For ER admissions, meet with members in the Emergency Room as per Health Home mandates.

• Staff Development:

1. Attending and participating in ongoing staff development training to enhance skills needed for the Care Coordinator position.

• Additional Responsibilities:

1. Ensure periodic evaluations and follow-up treatments for dental, vision, and hearing care per Medicaid guidelines.
2. Perform other duties as assigned.

• Physical Requirements:

1. While performing the duties for this job, the employee is regularly required to communicate clearly and effectively. The employee is required to stand, use mobility, handle, feel, and reach. The employee is occasionally required to climb stairs, sit and stoop, kneel or crouch. The employee may occasionally lift and/or move up to 25 pounds

• Qualifications for Care Manager:

1. Education and Credentials: Bachelor’s Degree Required: Social Work or a related field.
2. Preferred: Bilingual Spanish-speaking candidates are highly encouraged to apply.

• Experience Requirements for High Acuity Members: Relevant Positions:

1. Case Planner Care Coordinator Case Manager Case Worker in a social service setting Specific Areas of Experience: Child Welfare ACS (Administration for Children's Services) Foster Care
2. Expertise and Experience: Serving children and families in child welfare, developmental disabilities, mental health, healthcare, or other systems. Providing preventive services.
3. Additional Requirements for High Acuity Enrollees: Demonstrated knowledge and understanding of the needs of high-acuity children and their families. Evidenced by additional years of experience, education, or training.
4. Experience with Medical Fragility: Extensive experience in coordinating care for children with medical fragility.
5. Service Coordination Skills: Providing service coordination. Information, linkages, and referrals for community-based services.