Manager II for Health Home Plus operates within a team of professionals who
deliver services to consumers who are identified as "high risk users of
services" and who have problems accessing care. High-risk users of services are typically
identified as those individuals who experience multiple emergency room or
inpatient services and/or present with behavioral health disorders coupled
with chronic disease syndromes. Health Home Plus Care Manager II identifies,
assesses, links to and monitors the use of multiple resources as well as
providing care to benefiting individuals in form of having weekly contact
with each client. Assessing for the appropriateness, quality, adequacy and
continuity of community resources and working closely with mental health
providers towards the goal of promoting integration. The Care Manager II
assists consumers enrolled in health homes in making informed choices,
accessing the most appropriate services to meet their needs and achieving
maximum level of independence in the most appropriate and least restrictive
- Intake and screening - initial contact, exploration
of the consumer's receptivity to services, verification that the consumer is
a member of the Care Management target population, identification of problem
areas and potential resolutions, and case information management.
- Assessment and reassessment - securing of information
through collateral sources of the nature and degree of the consumer's
functional behavioral health impairment, eligibility for services,
identification of barriers to care and gaps in service, assessment of service
needs (including vocational, medical, social, psychosocial, educational,
financial and other services), description of strengths, informal support
system identification and environmental factors relative to consumer's care.
- HARP assessments - take appropriate training
needed to do HARP assessments.
- Care management planning and
comprehensive written care management planning and coordination include
identification of the nature, amount frequency and duration of care
management services required by the consumer, long term and short term goals
and objectives to be achieved through the care management process and
collaboration with health home, health care providers and other service
providers, including informal care givers.
- Implementation of care management
plan - providing
and/or securing the services determined in the care management plan.
- Monitoring and follow-up- assuring that quality services
identified in the care management plan are delivered, assuring the consumer's
satisfaction with the services provided, collecting data and documentation in
case records, necessary revision of case records, necessary revision of care
management plans, and problem resolution.
- Counseling and exit planning - facilitating the introduction
and linkage to support groups for the consumer, the consumer's family and
informal providers of services, mediating within the consumer's network,
facilitating the consumer's access to appropriate care and preparing the consumer
for discharge from or admission to facilities or other programs including
health home care managers to insure continuity of care.
be available to transport consumers to appointments and/or community
resources when needed.
- Please note, your schedule and
assigned duties are subject to change based on the needs of the program and
the clients we serve.
of behavioral health diagnoses and symptomatology
familiarity with community resources, including entitlement programs,
medical, financial and legal services, housing and emergency food programs,
and the range of behavioral health treatment and rehabilitation services
be able to effectively engage treatment resistant individuals.
have an understanding of issues related to complex diagnostic cases, such as
chronic disease/behavioral health interactions.
be able to effectively broker services and develop resources.
be able to perform duties in an independent and efficient manner.
possess knowledge of and ability to provide behavioral health interventions
in coordination of care.
Supervision from the Senior Care Manager Supervisor