Role and Responsibilities Provide collaborative, client-centered support to Health Home Program clients using the development of person-centered goals, culturally competent care management, and professional healthcare and social service coordination. Health Home Care Managers will evaluate, manage, and integrate solutions and resources for all primary, complex chronic diseases, behavioral health and long-term care needs in the Health Home Program. This position is designated as a higher-skilled Care Manager, capable of exceeding the basic tenants of care management. Essential Functions + Actively and progressively care manage an enrolled client caseload as determined by Agency guidelines. Develop an individualized plan of care with specific goals/interventions/objectives, to be revised as needed. + Provide rehabilitative and supportive counseling geared toward the restoration of clients to their optimum level of social and health functioning. This includes assisting clients and their families with the adjustment to their illness and following medical/behavioral health recommendations. + Assist the clients and their families with personal and environmental difficulties, which predispose them towards illness and/or interfere with obtaining maximum benefits from medical care. + Timely completion of individualized assessments specific to program needs utilizing NYS HCS-UAS system. + Develop long- and short-term plans, when appropriate, including the utilization of community supports with the goal of reducing emergency room and/or in-patient utilization. + Communicate directly with members of the care team to provide up-to-date information regarding the clients care to effectively reduce duplicative services. + Consult with the physicians, Managed Care Organizations and other members of the Care Team for the purpose of educating them on the social, emotional and environmental factors related to the clients barriers to success. + Prepare concise, accurate, and timely case notes which are incorporated into the clients records. + Complete client documentation within 24-hours. + Proficiently and accurately use multiple software systems to capture care management notes and related activities, and to provide corrections when needed regarding documentation in any one of the EMRs as needed, including the Lead Health Home systems, and HCRs Database. + Attend case conferences and act as a consultant to other agency personnel regarding clients psycho-social issues. + Perform required face-to-face client encounters in conformance with Health Home and Agency guidelines, adjusting frequency and duration based on client needs. + Schedule and maintain client visits, follow-up calls, and provider engagements utilizing effective time management skills. + Document active/progressive care management showing multiple points of engagement with a client or collateral contacts over the course of a month. + Timely discharge of clients no longer engaged in the Health Home Program. + Represent Care Management on agency committees and interdisciplinary team meetings as requested, as well as operate as an ambassador for HCR Care Management out in the community. + Network with community-based agency personnel to promote HCR and its services. + Meet/exceed performance expectations as outlined in Care Management Expectations. + Other duties as assigned.