The Children’s Health Home Program is a NYS initiative that serves children on Medicaid (up to age 21) with complex medical and/or behavioral conditions, and provides coordinated care management services to improve their care and reduce costs. This is done primarily through the work of a Care Manager who is responsible for ensuring the overall provision and coordination of services to children in an assigned caseload, working in collaboration with an interdisciplinary team. The Care Manager guides program enrollees and their caregivers (legal guardians) through the health care system by assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes.

MAJOR DUTIES & RESPONSIBILITIES:

• Works closely with the child and their caregiver(s) as well as the child’s care team at NAC and in the community.
• Ensures required program enrollment consents are obtained from the caregiver/consenter.
• Completes initial and ongoing needs assessments (Child and Adolescent Needs and Strengths; CANS-NY) to determine the child’s most appropriate level of care management. Enters CANS-NY data into NYS online portal.
• Responsible for the overall creation and management of the child’s Individualized Plan of Care (POC), by working collaboratively with the child and family and the child’s care team. Based on the POC,  the Care Manager is able to:

1. Coordinate the enrollee’s provision of services, as per their acuity level.
2. Support adherence to treatment recommendations.
3. In consultation with clinical and health care staff, monitor and evaluate a child’s needs, including prevention and wellness care, conditions affecting the child’s medical and mental health, care transitions, and social and community services where appropriate.

• Meets client contact requirements, including face-to-face visits in the child’s home on a consistent schedule as per the acuity level determined for each child (high, medium, low).
• Meets Care Management documentation requirements in a timely and accurate manner by effectively utilizing designated Care Management Portal (Medicaid Analytics Performance Portal; MAPP) and Electronic Health Records (EHRs) as needed
• Functions as an advocate for clients within the agency and with external service providers.
• Promotes prevention and wellness care linking enrollees with resources and services based on their individual needs and preferences.
• Works with health care staff at the agency and in the community to educate the child/caregiver(s) on care of chronic conditions, importance of immunizations, screening tests and other preventive interventions.
• Helps clients obtain health care services covered by Medicaid or their Managed Care Plan.
• Effectively communicates and shares information with the child and family/caregiver(s) with appropriate consideration for language, literacy and cultural preferences.
• Coordinates and conducts care planning meetings/conferences and serves as an interdisciplinary team member to effectively provide/coordinate comprehensive and holistic care.
• Identifies available community-based resources and actively manages appropriate referrals, access, engagement, follow-up and coordination of services.
• In the event of hospital admissions, participates actively in the discharge planning process to ensure that the transition home is supported by the provision of necessary services and treatments, all in place at the time of discharge.
• Attends and participates in ongoing staff development trainings to enhance skills needed to effectively meet the demands of the Care Manager position.
• Ensures child has periodic evaluations and follow up treatment for dental, vision and hearing care, following Medicaid EPSDT guidelines.
• All other duties, as required by agency.

QUALIFICATIONS & COMPETENCIES:

• A Master’s Degree in Social Work, Health Education, Community Health or related field.
• Work experience in a Bridges to Health, Care at Home, and Targeted Case Management programs a plus.
• Bilingual Spanish Required

The ideal candidate will possess the following experience:

• Experience serving children and families in child welfare, developmental disabilities, mental health, health care and/or other systems.
• Experience providing service coordination and information, linkages, and referrals for community-based social and/or health care services.

In addition, the candidate must demonstrate the following competencies:

• Excellent communication and organizational skills.
• Able to work collaboratively with an interdisciplinary care team.
• Demonstrated initiative and interpersonal ability to communicate with a variety of providers and negotiate/advocate on behalf of clients.
• A passion for serving children and families with special needs.
• Ability to travel to community-based agency offices, participant’s communities, and homes within assigned catchment area.
• Proven self-management abilities, including meeting deadlines, ensuring compliance with agency policy and procedures, and overseeing complete and timely maintenance of agency records, in accordance with contractual requirements.

How to Apply:   

Please indicate Bilingual Care Manager in the subject line when applying. Please submit cover letter and resume to: hr@nackidscan.org