Health Homes Plus Case Manager

SUMMARY:

The Health Home Plus (HH+) Care Manager is expected to provide intensive case management services to adults with Serious Mental Illness (SMI) enrolled in the HH+ program.

RESPONSIBILITIES:

• maintain a caseload of up to 20 clients, conducting assessments, developing care plans, providing service referral/navigation and crisis intervention
• Recommend and implement strategies to persuade members to fully participate in the program
• Accurately document services and outcomes to ensure compliance with billing and quality standards
• Deliver a minimum of 4 HH+ core services monthly—2 must be face-to-face
• Adhere to organizational protocols and contractual obligations from CBC, OMH and DOH under the HH+ program model
• Attend regular internal team meetings to review caseload progress and goal attainment
• Provide coordination with behavioral health or medical providers, facility or family members and/or community agencies regarding treatment and/or care plan issues
• Monitor client’s progress toward their care plan goals via telephone and/or in-person visits, and document via care plan outcomes and detailed progress notes
• Work with clients to break through barriers to member goals and to assist clients in advocating for themselves and move toward self-sufficiency
• Follow-up with clients for a period of time after successful completion of their primary goals to assure member stability