Assumes primary responsibility for performing and coordinating the services and functions necessary to enhance the client’s autonomy, quality of life, and recovery process in compliance with the Health Home Care Management guidelines.
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 OMH.
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.
Works in conjunction with the client, his or her residential team, family member, and any other provider of service to ensure continuity of care.
Conducts regular reviews of the Plan of Care with the client in an effort to evaluate progress and make revisions when needed.
Documents at least one progress note per month for each Health Home client detailing provision of service related to one of the Core Services as outlined by the Plan of Care and DOH guidelines.
Ensures timely completion of the Eligibility Assessment, creation and maintenance of the Plan of Care, and referrals to Home and Community-Based Services for clients in Health and Recovery (HARP) managed care plans in accordance with DOH requirements.
As assigned, completes at least 3 additional monthly services for clients enrolled in the Health Home Plus program.
Maintain accurate information on each client within the Electronic Health Record, 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.
Ensures that annual appointments for physicals, eye exams, and dental appointments are scheduled. Ensures that transportation is arranged for these appointments (when appropriate).
Makes referrals (i.e.; educational, vocational, medical, clinical, for entitlement) for the overall well-being of the client in alignment with goals identified in the plan of care, and assists client in maintaining on-going engagement in services.
Adheres to the care management guidelines for monthly Medicaid billing requirements for all Health Home clients.
Assists in recruiting perspective Health Home clients by assessing their needs for Care Management services.
Assists with submitting the Care Management referral to the appropriate Health Home agency.
Coordinate with SHP residents to coordinate completion of HARP HCBS Eligibility Assessments in accordance with established SDE contracts.
Maintain on-going communication with Managed Care Organizations and Behavioral Health Organizations associated with clients, including assessment, plan of care and service information.
Complete initial and on-going trainings as assigned by supervisor, agency, Health Home and DOH.
Respects and maintains the client’s confidentiality and demonstrates a caring, positive attitude toward all clients, staff, guests and service providers.
Provide safe transporting of clients when needed.
Follow all safety rules and regulations for self, clients and staff.
Performs any other duties necessary for the effective operations of the program.
Bachelor’s degree in Human Service field and 2-years of experience in providing services to individuals with Serious Mental Illness, Substance Use Disorders and/or Developmental Disabilities required.
* In addition to the above criteria this position also requires a clean NYS driving record as outlined in DePaul’s personnel policy.