SCO Family of Services has provided vital human services throughout New York City and Long Island for more than 100 years. SCO helps vulnerable New Yorkers build a strong foundation for the future. We get young children off to a good start, launch youth into adulthood, stabilize and strengthen families and unlock potential for children and adults with special needs.

SCO Family of Services welcomes you to join our family and help us work together to carry out our mission to build a stronger tomorrow.

PURPOSE OF THE POSITION: The Care Managers service youth who are enrolled in Medicaid, have two or more chronic conditions, HIV/AIDS, Sickle Cell, Serious Emotional Disturbance (SED), Serious Mental Illness (SMI) or Complex Trauma, ages 0-21 (Children’s Program) & 18 to end of life (Adult Program). The Care Manager plays a critical role in achieving the overall goals for coordination, integration and partnership in the delivery of care to children, adults and families with complex needs.

SPECIFIC RESPONSIBILITIES

1. Obtain required Care Management enrollment consents from the medical consenter to process enrollment into the Care Management Program.


2. Complete initial and ongoing needs assessments such as the Comprehensive Assessment, Child Adolescent Needs and Strengths-New York (CANS-NY) and NYS Eligibility Assessment for HARP.


3. Responsible for the development and overall management of the Plan of Care (POC). Through the development of the POC the Care Manager is able to:

• Coordinate the member’s provision of services, including providing Care Management Services as identified in the five core services based on the member’s acuity level.


• Support adherence to treatment recommendations and assist/facilitate with referrals, while ensuring follow-through of these referrals.


• Monitor and evaluate a youth’s needs, including but not limited to: Prevention, Wellness, Medical, Mental Health, Care Transitions, and Social and Community Services where appropriate.

Meet the standard billing requirement for each member based on their acuity score. Care Managers should keep in mind that caseloads will most often be “Blended” (Consisting of High, Medium and Low Acuity & Adults and Children (Family Model)).

Based on acuity level provide the required face-to-face contacts on a consistent schedule as per the Department of Health’s mandates for High, Medium and Low acuity levels.

Ensure Care Management documentation is completed in a timely and accurate manner by effectively utilizing the daily activity log, and electronic health record.

Function as an advocate for the member within the agency and external service providers.

Promote wellness and prevention by linking youth with resources and services based on their individual needs and preferences.

Educate the member/caregiver on Chronic Conditions, Immunizations, Screenings and other preventative interventions.

Assist the member to obtain and maintain public benefits necessary to gain health care services, including but not limited to: Medicaid, Cash Assistance Eligibility, Social Security, Supplemental Nutrition Assistance Program, Housing, Legal Services, Employment and Training Supports.

Effectively communicate and share information with the individual and their families and other caregivers with appropriate consideration for language, literacy, and cultural preferences.

Conduct care planning meeting/conferences and serve as an interdisciplinary team member to effectively provide/coordinate comprehensive and holistic care.

Identify available community-based resources and actively manage appropriate referrals, access, engagement, follow-up and coordination of services.

In the event of hospital admissions, actively engage in the discharge planning process ensuring that the patient has recommended post-discharge services in place prior to scheduled discharge.

Attend and participate in ongoing staff development training to enhance skills needed to effectively meet the demands of the Care Manager position.

Ensure all members enrolled have periodic evaluations and follow-up treatment for Dental, Vision, and Hearing Care as per the Medicaid EPSDT guidelines.

Develop a close working relationship with the child’s case planner and/or case manager (if applicable).

Ability to travel within 5 boroughs and Nassau and Suffolk County.

Perform all other duties as assigned.

QUALIFICATIONS

• Bilingual Preferred.


• Health Home Care Managers that serve children with an acuity level of “high” as determined by the CANS-NY or that serve adults with Health Home Plus status must have:




• A Bachelors of Arts or Science with two years of relevant experience, OR


• A License as a Registered Nurse with two years of relevant experience, OR


• A Masters with one year of relevant experience.




• Designated Health Home Care Managers for SED serving children with an acuity level of “medium” as determined by the CANS-NY must have:




• At least an associate’s degree with one year of relevant experience.




• Expertise and experience in servicing youth, adults and families in child welfare, developmental disabilities, mental health, healthcare and/or other systems as well as those receiving preventive services.


• Passion and knowledge for advocating on behalf of staff, children, adults and families.

In addition, employees need to possess the following characteristics:

• Be a Strong team player.


• Possess excellent communication and leadership skills.


• Work well with others and feel comfortable providing direction and guidance to peers.


• Evidence of the ability to practice a high level of confidentiality.


• Develop a trusting and supportive relationship with peers, members and the team.


• Have a strong sensitivity to cultural differences presented among staff and clients within the agency.


• Possess a strong belief in people’s ability to grow and change; forge a mutually respectful partnership with persons served and their families.


• Demonstrate excellent crisis intervention skills and have the ability to remain calm while handling crisis situations.


• Ability to set limits and maintain the helping role of practitioner and to intervene appropriately.

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