Provides comprehensive Health Home care management services for GRHHN clients/patients assigned to VNSC. This includes managing a caseload and working with outreach workers and the client care team to engage, enroll, assess, develop, and carry out a comprehensive care plan to address all medical, behavioral health, substance abuse and psychosocial needs of the client.

Qualified individuals must be capable of performing the following essential duties and responsibilities, with or without reasonable accommodations:

• Finds, engages and enrolls clients in GRHHN health home program per CMS and NYSDOH regulations and GRHHN procedures.
• Completes assessment of needs, strengths and goals
• Provides assistance with housing, transportation, food, clothing, and other barriers to optimum health.
• Drafts and communicates suggested plan of care and discusses at Care/Service Team. Reviews and revises a comprehensive plan of care with the client to meet needs in collaboration with the service team/providers.
• Implements client approved plan of care with Service Team.
  • Provides comprehensive care management including self management support, health promotion, connection/referrals to providers, community based organizations, social supports, transitions of care, and crisis support with the goal of decreasing barriers to attending appointments and following the plan of care.
  • Provides care coordination with Primary/Specialty Medical care, acute and outpatient medical, mental health, substance abuse services, and other care managers involved in supporting the client.
  • Provides comprehensive transitional care involving coordination of care and services following critical events such as emergency department use, hospital inpatient admission and discharge.
  • Provides crisis intervention addressing events such as emergency department visits or inpatient or other crisis events to assure interventions are effective and necessary modifications to plan of care are made.
  • Provides family and caregiver support.
  • Ensures language access/translation capability.
• Modifies goals and Care Team membership as appropriate to meet client needs.
• Shares information between team members and care providers.
• Coordinates client care team meetings.
• Documents activities and their effectiveness in shared care management software tool.
• Documents elements necessary for quality improvement and to meet reporting requirements.
• Participates in the recruitment and training of additional care managers and community outreach workers as program volume grows.
• Participates in the intake process for member assignments from GRHHN to provide health home services.
• Participates in obtaining and reporting the CMS and NYSDOH requirements.
• Participates in implementation of health IT functionalities and applications as required by the health home.
• Participates in on call for 24 hour 7 days a week telephone access to a care manager particularly after hours.
• Other duties as assigned.

• Note: The above information on this job has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.

Education & Experience - Applicants must possess the following qualifications or an equivalent combination of education and experience:

• Education: NYS Licensed Healthcare Professional – RN or SW preferred, otherwise a Bachelor’s degree with a minimum of three years of experience in a Human Services position or an Associate’s Degree in Human Services and five years’ related experience.
• Experience: Minimum of 3 years of relevant clinical experience with the Health Home’s target population. A combination of chronic care management, substance abuse, mental health and community experience highly desirable.

Licensure, Certification, and/or Credential Requirements

• NYS Licensed Healthcare Professional – RN or SW preferred.
• Must have a valid Driver’s License and proof of auto insurance.

Physical Requirements: The position involves frequent sitting, standing, and walking. Occasional bending and pushing may be required. Tasks such as kneeling, squatting, reaching, twisting, balancing, climbing, and pulling are required infrequently.

Job Code: 724

Salary Range: $22 - $43

The referenced pay range represents the minimum and maximum compensation for this job family. Individual annual salaries/hourly rates will be set within the job’s compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.