I. SPECIFIC RESPONSIBILITIES

 Work in conjunction with the Family Partner and Youth Partner to ensure youth and families drive the
development and implementation of their own care plan of care.
 Support families to lead the process in developing and implementing their own plan of care. Over time
families aim to move towards increased reliance on “natural supports” in their communities.
 The HFW model does not prescribe frequency of service contact or maximum length of stay so that
service provision can be tailored to the individual needs of each youth and family; however, at a
minimum, the HFW team will offer the frequency of contact required of Health Home serving high acuity
and HFW enrolled youth (four contacts a month, two being face to face).
 Obtain required Care Management enrollment consents from the medical consenter to process
enrollment into the Care Management Program.
 Complete initial and ongoing needs assessments such as the Child Adolescent Needs and StrengthsNew York (CANS-NY)
 Responsible for the development and overall management of the youth’s Wraparound Plan. Through
the development of the plan the Care Manager is able to:
1. Coordinate the youth’s provision of services, including providing Care Management Services as
identified in the five core services based on the youth’s acuity level.
2. Support adherence to treatment recommendations and assist/facilitate with referrals, while
ensuring follow-through of these referrals.
3. Monitor and evaluate a youth’s needs, including but not limited to: 1. Prevention 2. Wellness 3.
Medical 4. Mental Health 5. Care Transitions, and 6. Social and Community Services where
appropriate.
 Meet the standard billing requirement for each youth
 Ensures documentation is completed in a timely and accurate manner by effectively utilizing the daily
activity log, and electronic health record.
 Function as an advocate for youth and families within the agency and external service providers.
 Promote wellness and prevention by linking youth with resources and services based on their individual
needs and preferences.
 Educate the youth/caregiver on Chronic Conditions, Immunizations, Screenings and other preventative
interventions.
 Assists the youth and family to obtain and maintain public benefits necessary to gain health care
services, including but not limited to: 1. Medicaid 2. Cash Assistance Eligibility 3. Social Security
Supplemental Nutrition Assistance Program 5. Housing 6. Legal Services 7. Employment and, 8.
Training Supports.
 Effectively communicates and shares information with the individual and their families and other
caregiver with appropriate consideration for language, literacy, and cultural preferences.
 Conducts care planning meeting/conferences and services and an interdisciplinary team member to
effectively provide/coordinate comprehensive and holistic care.
 Identified available community-based resources and actively manages appropriate referrals, access,
engagement, follow-up and coordination of services.
 In the event of hospital admissions, actively engages in the discharge planning process ensuring that
the patient has recommended post discharge services in place prior to scheduled discharge.
 Attend and participate in ongoing staff development training to enhance skills needed to effectively
meet the demands of the Care Manager position.
 Ensure the child has periodic evaluations and follow-up treatment for: 1. Dental 2. Vision and 3.
Hearing Care as per the Medicaid EPSDT guidelines.
 Development of a close working relationship with the child’s case planner and/or case manager (if
applicable).
 Receive intense training, regular supervision and coaching in the implementation of the HFW model.
 Attend and fully participate in the HFW training offered by Columbia Practice Innovations (CPI). After
the first year of training as a team the Care manager will complete any additional tasks to become
HFW-certified and maintain certification.
 Ensure documentation requirements are being met.
 Perform all other duties as assigned.

II. QUALIFICATIONS
 HFW Care Managers must meet the following minimum qualifications:
1. Bachelors of Arts or Science with two years of relevant experience, or
2. A License as a Registered Nurse with two years of relevant experience, or
3. A Masters with one year of relevant experience.
4. Preference for individuals who identify as having lived experience with systems of care.
 NYS Wraparound (HFW) Certification requirements include:
1. Successful completion of the HFW training;
2. Attendance in live classroom skill clinics, topic specific TA sessions, and role specific TA
sessions;
3. Participation in team specific coaching at a monthly implementation meeting, team case
presentations, audio recordings and documentation requirements.
 CANS-NY training and annual recertification.
 Meet all Lead Health Home training requirements.
 Expertise and experience in servicing children and families in child welfare, developmental disabilities,
mental health, healthcare and/or other system as well as those receiving preventive services.
 Passion and knowledge for advocating on behalf of staff, children and families.

Salary: 50k-52k