Assumes primary responsibility for performing and coordinating the services and functions necessary to enhance the client’s autonomy, quality of life, and recovery process. This includes compliance with the Health Home / Care management guidelines. In addition will provide direct support to coordinate and enhance the client’s care.
*Please note, this position is Monday-Friday, 8:00AM-4:30PM
1. Develops the overall Plan of Care with the client and his or her support network by identifying the
client’s needs and desires in an effort to help the client live as independently as possible.
2. Works in conjunction with the client, his or her residential team, family member, and any other
provider of service to ensure continuity of care and makes certain that Care managers do the same
for their respective clients.
3. Ensures that each client receives comprehensive Care Management planning and assessments in a
person-centered approach. Ensures that each Plan of Care is complete and that assessments are
up to date and in accordance with standard of practice as outlined by the NYS DOH and the NYS
4. Conducts 6 month reviews of the Plan of Care with the client in an effort to evaluate progress and
make revisions when warranted.
5. Documents at least one progress note per month in client’s file that relates to the client’s core
services as outlined in the Plan of Care.
6. Maintain accurate and timely client files, including the documentation of progress notes, the
updating of Care Plans, the maintenance of psychiatric and medical records, as well as other
pertinent information regarding the client.
7. Ensures that annual appointments for physicals, eye exams, and dental appointments are
scheduled. Ensures that transportation is arranged for these appointments (when appropriate).
8. Makes referrals (i.e.: educational, vocational, medical, clinical, for entitlement) for the overall well
being of the client based on their own specific wants and needs.
9. Serves as the overall team leader along with the client to communicate all pertinent information to
all members of their client support network.
10. Works with the client and the residential staff to ensure clothing items and other necessities are
provided as needed.
11. Works with clients to encourage a healthy connection with family and community ties and to
develop new supports and interests as desired.
12. Adheres to the care management guidelines for monthly Medicaid billing requirements.
13. Maintain compliance with governmental agencies reporting responsibilities with regard to the Care
14. Assists in recruiting perspective clients by assessing their needs for Care Management services.
15. Assists when appropriate with submitting the Care Management application to the appropriate
Health Home agency.
16. Respects and maintains the client’s confidentiality and demonstrates a caring, positive attitude
toward all clients, staff, guests, and service providers.
17. Provide safe transporting of clients when needed.
18. Follow all safety rules and regulations for self, clients, and staff.
19. Performs any other duties necessary for the effective operations of the program.