Care Manager II - Health Home

Company: Monroe Plan for Medical Care
Location: Albany
Posted on: November 26, 2022

Job Description:

Want to be a part of an amazing organization? An organization that makes a difference in the lives of individuals each and every day? Monroe Plan for Medical Care is a not-for-profit health care services organization that has been meeting the needs of our members in the Greater Buffalo, Rochester, Syracuse, Binghamton and Albany Regions for 50 years. Monroe Plan provides health home services and other critical health care services to individuals covered by Medicaid, Child Health Plus and the Essential Plan. Monroe Plan was recently the recipient of the Top Workplaces Awards in 2022! Following our mission and vision to improve the health status of individuals and families, Monroe Plan's innovative clinical care management programs are structured to meet the unique needs of members, providers, health care organizations and the communities we serve. Monroe Plan has consistently been recognized as a national leader in the "safety net" area, with a proven track record of improving health outcomes and reducing disparities by supporting a health care delivery system that ensures the availability of high quality medical care for all. We are currently looking for experienced and qualified care managers. We offer competitive pay, flexible schedules and great benefits. If you are passionate about helping individuals and working one on one with them, this might be the right fit for you. Our mission encompasses compassion, empowerment and teamwork. We believe if we are supportive and compassionate to our employees, it will spill over to our members. Candidate must be willing to travel throughout the Albany area; candidate should have previous experience working with adults POSITION SUMMARY
Provides care management services to specific population eligible for Health Home services. Provides information, referrals, consultation and/or care management on health and psychosocial issues. This position works with substantial independence in the field, with consultation available from Clinical Team Lead and/or Supervisor, as needed. ESSENTIAL JOB DUTIES/FUNCTIONS % of Time Essential Function 50% Care Management - Receives referrals of members for Health Home services from internal and external sources. - Contacts referral within appropriate timeframe, addresses any urgent /emergent issues and schedules an appointment for a face to face intake, within required time frame. - Conducts comprehensive bio-psycho-social assessments for adults and children using NYS and agency approved processes and documents - Develops therapeutic relationship with member utilizing person centered interventions based on the member's level of activation and presenting conditions - Coordinates services through communication with all identified health and community providers/agencies connected to the member - Develops a Person Centered Plan of Care with the member and involved providers. - Disseminates this information to all individuals who are involved in members' care, as approved by member. - Interviews referrals and their families to collect data, disseminate pre-approved health education information, and administer satisfaction surveys and related evaluative inventories - Determines need and makes recommendations for continuation of or change in services - Maintains, at minimum, monthly telephonic contact with the member and an in-person visit at minimum once every three months. Contacts may be more often depending upon the acuity and/or complexity of the member's current condition or situation. - Seeks out consultation/information for complex medical, behavioral health or psycho-social, as needed - Recognizes cultural differences, demonstrates responsiveness to those differences when working with members and others in the community - Travels as required for home visits and other community activities - Adheres to Monroe Plan professional boundaries and protocols. 30% Documentation - Completes all required documentation in a complete, clear, concise and timely fashion insuring that the information presented is readily understood and actionable by team members - Must be able to pass computer documentation competency testing for all software platforms used within the program. This must occur within 3months of initial training and/or 6 months of hire, whichever comes first. - Completes all necessary assessments to include, but not limited to the Health Assessment Tool, Patient Activation Measure (PAM), Health Home authorization, HML assessment within regulatory time frames - Documentation of a Person-Centered Care Plan, in collaboration with the client and providers - Review and update of assessments, as mandated by regulations - Maintains documentation that is thorough, clearly written and reflective of members' plan of care activities. Documentation needs to be completed at minimum 1x/month and more often as contacts and actions occur in the members' case. - Documents in electronic record regarding care management/coaching activities and termination as appropriate - Prepares required reports - caseload reports, case logs, etc. as requested 15% Case Review & Collaboration - Participates as a member of multi-disciplinary Care Coordination team - Prepare for and participate in case review meetings with the Health Home Clinical Lead to share cases, discoveries, concerns and collaborate in the development of plans of action. - Presents members for review every 90 days or more often, as condition requires - Initiates and facilitates member focused meetings to include the member, community providers and significant others, as identified by member for the purpose of care coordination and establishment of a natural support group - Participates in inter-agency teams to enhance the work environment and provision of services for members - Participate effectively as a team member within the Monroe Plan team by fostering a positive working relationship with members, providers and Monroe Plan staff; working effectively with others to coordinate member and access care support services; supporting team members for cross coverage as work load dictates. - Collaborate with other members of Health Home staff related to member needs, barriers to care and outcome enhancement strategies. - Manages conflict to support a positive outcome - Participate in community activities to promote health and public awareness using Monroe Plan specified materials. - Assists in locating members in the community through home visits and collaboration with known providers - Attend and participate in inservice training 10% Communication - Presents in a professional and articulate manner that supports the development of a therapeutic relationship with the member and community providers - Provide feedback to providers regarding the progress made and barriers encountered by their patients - Demonstrates listening skills to support member engagement and development of a person centered plan of care - Provide program information to members and providers, and other organizations as requested to introduce and support program participation. Total must equal 100% - essential functions should be completed at least 10% of the time OTHER FUNCTIONS AND RESPONSIBILITIES Position Limitations: -Cannot perform any tasks which are governed by license or registration (i.e. cannot answer questions or make recommendations RE diagnosis, medications or treatment). -Cannot transport active Monroe Plan members at any time. -Cannot perform hands on care. MINIMUM REQUIREMENTS/LICENSES/CERTIFICATIONS - Master's degree in Social Work, Psychology, Nursing, Rehabilitation, Education, OT, PT, Recreation, Counseling, Community Mental Health, Child & Family Studies, Sociology, Speech & Hearing or other Human Services field AND 1 year of experience providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse and/or children with SED; or linking individuals with Serious Mental Illness, children with SED, developmental disabilities and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting.
- Bachelor's degree in Social Work, Psychology, Nursing, Rehabilitation, Education, OT, PT, Recreation, Counseling, Community Mental Health, Child & Family Studies, Sociology, Speech & Hearing or other Human Services field AND 2 years of experience providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse and/or children with SED; or linking individuals with Serious Mental Illness, children with SED, developmental disabilities and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting.
- Credentialed Alcoholism and Substance Abuse Counselor (CASAC) AND 2 years of experience providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse and/or children with SED; or linking individuals with Serious Mental Illness, children with SED, developmental disabilities and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting.
- Bachelor's degree or higher in ANY field with either 3 years of experience providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse and/or children with SED; or linking individuals with Serious Mental Illness, children with SED, developmental disabilities and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting OR 2 years of experience as a Health Home Care Manager serving the SMI or SED population.
- Demonstrates ability to respect individual/family diversity and maintain confidentiality.
- Demonstrates ability to work as a team member.
- Knowledge of and ability to work collaboratively with providers and county/community health and human services.
- Ability to demonstrate excellent communication skills both oral and written as well as strong interpersonal skills.
- Proven ability to work independently and to manage time appropriately
- Strong organizational skills.
- Computer literate.
- Candidates will need a NYS driver's license and to own or have access to reliable transportation that enables them to fulfill travel requirements of the job including but not limited to, daily visits to members' homes. Preferred Qualifications
- Previous experience working as a Health Home Care Manager PHI MINIMUM NECESSARY USE: This staff position PHI access will be determined based on Minimum Necessary standards. The Minimum Necessary Grid can be found on the Human Resources and Compliance Web pages. This job description is only a summary of the typical functions of the job, not an exhaustive or comprehensive list of all possible job responsibilities, tasks and duties. Additional responsibilities, tasks and duties may be assigned as necessary. Monroe Plan for Medical Care is an Equal Opportunity Employer

Keywords: Monroe Plan for Medical Care, Albany , Care Manager II - Health Home, Healthcare , Albany, New York