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Adult Health Plus Care Manager



JOB SUMMARY: Under the supervision of the Health Home Unit Supervisor, the incumbent is responsible for the day-to-day provision of multiple concrete services within a psychosocial context, to include referrals, advocacy and crisis intervention. Incumbent will be responsible for caseload of 12-15 Adult Health Plus clients. All responsibilities must follow BAC and Health Home guidelines and standards.
Comprehensive documentation of all services provided on a timely basis. Responsible for maintaining updated and accurate individual records.
Maintain a caseload of 12-15 Adult Health Plus clients
Assist clients with transition from Nursing Home to the community
Coordinate transition of clients' move from Nursing Facility to the community
Sit in on weekly State mandated client appraisal calls
Ensure clients receive the required number of visits per month
Responsible for developing a wellness coaching relationship with clients and assisting clients through the process of working toward better health through support, encouragement and education. Conduct Quality Assurance activities for the Health Homes program on a monthly frequency.
Provide technical assistance and training for Health Homes team on a as needed basis
Keep abreast of industry and program policies and procedures to ensure that technical assistance is provided to the team regarding all current and pertinent Health Homes guidelines.
Responsible for ensuring HMLs are completely timely.
Responsible to work in a team model and ensure on-going contact (or attempts to contact) clients on caseload.
Responsible to complete assessments, (reassessments and service plans as specified by BAC and Health Home guidelines.
Responsible to make a home visit to assess needs of family unit and to incorporate the needs of the family into services plans unless a barrier is documented.
Responsible to record all contracts and transactions with clients, collaterals and service providers. Responsible for developing a comprehensive written care plan, including coordination of services provider responsibility.
Responsible to complete closing and transfer summaries.
Responsible to provide statistical data on each individual case.
Assessing emergency needs and identifying types of intervention in crisis intervention situations. Responsible to provide supportive counseling to assist implementation of the service plan and encoura es client self-sufficienc and em owerment.
Making home visits and other required contacts.
Monitoring of case management services to ensure that services are provided, and client is engaged in care plan and promotes compliance with medical appointments.
responsible to participate in case conferences (both internal and external)
Responsible for ensuring that case records and billing documentation is complete, accurate, and up to date.
Attending meetings, trainings and development seminars.
Work with supervisor to identify systematic challenges and apply organized approach (i.e. Plan-DoStudy-Act cycle) to facilitate continuous quality improvement.


•Use individual patient data to inform clinical decision-making and identify areas for improvement; use data to track patient progress over time.
•Sharing client data with clients to help facilitate shared-decision making and keep client informed of his/her progress
•Work with entire Bridging Access to Care team to apply a continuous quality improvement approach (i.e. the Plan-Do-Study-Act cycle), to address systemic, organization-wide challenges.
•Complete QI training during onboarding process and participate in QI refresher training as needed.
Complete Sections 1-5 of CPI Trauma Informed Approach during onboarding process and participate in Trauma Informed care refresher training as needed.
o Understanding the bidirectional relationship among substance use, mental disorders & Trauma
o Knowledge of trauma-informed theories, principles, and practices (includes multi-faceted understanding of concepts such as community trauma, intergenerational and historical trauma, parallel processes, and universal precautions).


$50K with great benefits


Posted on 05/01/19; CVMHA ID #12778