The Care Manager for Children’s Health Home provides patients advocacy, outreach, education, and clinical services.
Skills and competencies required for the position include communication, cultural competence, training professional
experiences, and education. The activities are tailored to meet the unique needs of the communities. The Care
Manager for Children’s health Home works closely to collaborate services to link at-risk youth to services and
programs that support that support functioning in the least restrictive community setting. The Care Manager work’s to
provide stability for at-risk youth who are chronically ill, underserved, mentally disable, and high inpatient and emergency
department utilizers. This position includes no managerial or supervisory responsibilities.
KEY ESSENTIAL FUNCTIONS:
- Provide direct coaching, education and advocacy in linking, engaging and retaining clients in services
- identified in the Plan of Care.
- Escort clients to appointments and provide and gather critical information, both in the field and in the
- office, with the goal of health and wellness promotion and a reduction in preventable negative health or
- social events.
- Elicit the support of all providers involved in a client’s care and ensure maximized communication among
- all parties via face to face contacts, phone calls, emails, case conferences, etc.
- Conduct vigorous outreach in identifying and locating potential clients either referred through the
- community or by the lead Health Home.
- Provide intensive care management services to clients living with chronic illnesses and their
- families/support systems and advocate aggressively for clients to obtain the full range of needed services
- and ensures coordination of these services.
- Ensures the timely completion of internal and external required assessments (Comprehensive
- Assessments, CANS-NY assessments, Eligibility and Appropriateness Assessment, etc).
- Ensures the timely completion of the initial Plan of Care and plan reviews based on Lead Health Home
- Ensures the Plan of Care for each enrolled member includes quality SMART goals, interventions and
- Completes progress notes in accordance with Health Home and departmental policies.
- Responsible for the overall chart compliance of assigned caseload members.
- Demonstrate the ability to clearly articulate, verbally and in writing, the aims and goals of the Health
- Home program and the process to potential clients and community members and Acacia Network staff.
- Responsible for coordinating and attending provider case conferences.
- Participate in quality improvement activities, projects and reviews.
- Complete periodic requests for narrative or quantitative data reports for program review.
- Identify new sources of potential clients and conduct outreach presentations as requested.
- Meet regularly with supervisor and attend staff meetings. Be prepared to discuss clinical and operational
- issues impacting performance and program operations.
- Complete and submit daily activity log in accordance with departmental policies.
- Maintain and update caseload tracking tool.
- Escort clients to entitlement offices to gain, maintain or regain eligibility; Verify client eligibility through
- ePaces, as requested.
- Conduct outreach in accordance with Health Home policy via phone, letter, and field work to
- client/collateral/provider/ support system to engage clients or strengthen connectivity.
- Conduct home visits on a monthly basis to members on caseload as needed to provide comprehensive
- care management services.
- Provide Diligent and Continued Search efforts in order to regain and maintain member engagement.
- Provide member referrals to Health Navigator and Outreach team via member referral to HHSA and
- Attend Supervision with Clinical Supervisor and Operations Coordinator as scheduled and be prepared to
- discuss topics around caseload, engagement, work related concerns, barriers, trainings, etc.
- Assess and respond per agency guidelines to client complaints or grievances.
- Help maintain health and wellness and prevent secondary disease complications.
- Ensure community-follow up to engage the client in care; promotes compliance with medical
- appointments and encourages client self-sufficiency and empowerment.
- Coordinate schedule and appointments with Health Navigator to ensure client attendance at appointments
- or engage in outreach efforts.
- Organize fieldwork to maximize delivery of service to clients.
- Utilize company issued cell phone to stay in contact with members/ providers/ Health Home team on a 24
- hour basis.
- Coordinate, communicate and support members within serviced boroughs.
- Coordinate and orchestrate IDT meetings between member, legal guardian/ parent, providers, ACS etc.
- Link at-risk youth to services and programs that support that support functioning in the least restrictive
- community setting.
- 1. High Intensity
- Education: Bachelor’s Degree in a social service or counseling discipline, also can be a nurse,
- doctor or another licensed healthcare professional
- Experience: 4 years preferred, (although additional education may substitute for u to 2 years of
- experience) in direct services to mentally disabled, chronically ill or other standard medical
- 2. Care Manager
- a. Education- an Associate’s degree with two years of experience or a Bachelor’s Degree- 1 year
- of experience. Education can substitute for experience
- b. Experience- 2 years of providing direct services to medically underserved populations.
- c. New York State Case manager- Individuals meeting these requirements.
- 3. On- Call Person for After- Hours
- a. Must be appropriately trained by the CMA to manage any urgent member calls.
- CANS-NY training and Certification annually
- o Care managers must be CANS-NY certified and must achieve at least a score of 70% or
- higher on exam.
- Mandated Reporter Certified
- Completed all mandatory trainings within six months of employment or from first date as a Care
- Excellent public speaking and presentation skills.
- Ability to communicate effectively orally and in writing.
- Ability to connect with others and forge strong relationships.
*Acacia Network is an equal opportunity employer*