FULL TIME POSITION - Monroe County Travel
Provides care management services to specific population eligible for Health Home services. Provides information, referrals, consultation and/or care management on health and psychosocial issues.
This position works with substantial independence in the field, with consultation available from Clinical Team Lead and/or Supervisor, as needed.
POSITION HAS DIRECT REPORTS: No
ESSENTIAL JOB DUTIES/FUNCTIONS
OTHER FUNCTIONS AND RESPONSIBILITIES
% of Time
| Care Management
- Receives referrals of members for Health Home services from internal and external sources.
- Contacts referral within appropriate timeframe, addresses any urgent /emergent issues and schedules an appointment for a face to face intake, within required time frame.
- Develops therapeutic relationship with member utilizing person centered interventions based on the member's level of activation and presenting conditions
- Coordinates services through communication with all identified health and community providers/agencies connected to the member
- Develops a Person Centered Plan of Care with the member and involved providers.
- Disseminates this information to all individuals who are involved in members' care, as approved by member.
- Interviews referrals and their families to collect data, disseminate pre-approved health education information, and administer satisfaction surveys and related evaluative inventories
- Determines need and makes recommendations for continuation of or change in services
- Maintains, at minimum, monthly telephonic contact with the member and an in-person visit at minimum once every three months.Contacts may be more often depending upon the acuity and/or complexity of the member's current condition or situation.
- Seeks out consultation/information for complex medical, behavioral health or psycho-social, as needed
- Recognizes cultural differences, demonstrates responsiveness to those differences when working with members and others in the community
- Completes all necessary assessments to include, but not limited to the Health Assessment Tool, Patient Activation Measure (PAM), Health Home authorization, HML assessment within regulatory time frames
- Development and documentation of a Person-Centered Care Plan, in collaboration with the client and providers
- Review and update of assessments, as mandated by regulations
- Maintains documentation that is thorough, clearly written and reflective of members' plan of care activities.Documentation needs to be completed at minimum 1x/month and more often as contacts and actions occur in the members' case.
- Documents in electronic record regarding care management/coaching activities and termination as appropriate
| Team and Cross- functional Responsibilities
- Participates as a member of multi-disciplinary Care Coordination team
- Prepare for and participate in case review meetings with the Health Home Clinical Leadto share cases, discoveries, concerns and collaborate in the development of plans of action.
- Presents members for review every 90 days or more often, as condition requires
- Initiates and facilitates member focused meetings to include the member, community providers and significant others, as identified by member for the purpose of care coordination and establishment of a natural support group
- Participates in inter-agency teams to enhance the work environment and provision of services for members
- Participate effectively as a team member within the Monroe Plan team by fostering a positive working relationship with members, providers and Monroe Plan staff; working effectively with others to coordinate member and access care support services; supporting team members for cross coverage as work load dictates.
- Presents in a professional and articulate manner that supports the development of a therapeutic relationship with the member and community providers
- Collaborate with other members of Health Home staff related to member needs, barriers to care and outcome enhancement strategies.
- Provide feedback to providers regarding the progress made and barriers encountered by their patients
- Ability to manage conflict to support a positive outcome
- Demonstrates listening skills to support member engagement and development of a person centered plan of care
- Provide program information to members and providers, and other organizations as requested to introduce and support program participation.
- Travels as required for home visits and other community activities
- Assists in locating members in the community through home visits and collaboration with known providers
- Participate in community activities to promote health and public awareness using Monroe Plan specified materials.
- Attend and participate in in-service trainings/meetings provided by Monroe Plan Health Home
- Develop and operationalize professional development goals throughout the year
- Adhere to Monroe Plan professional boundaries and protocols.
- Performs other duties as assigned.
- Cannot perform any tasks which are governed by license or registration (i.e. cannot answer questions or make recommendations RE diagnosis, medications or treatment).
- Cannot transport
- Cannot perform hands on care.
- Bachelor's Degree or above in Social Work, Counseling or related field with a minimum of 2 years' experience in a community outreach or equivalent position or a combination of training and education that meets the above knowledge and skill level
- Demonstrates ability to respect individual/family diversity and maintain confidentiality.
- Demonstrates ability to work as a team member.
- Knowledge of and ability to work collaboratively with providers and county/community health and human services.
- Ability to demonstrate excellent communication skills both oral and written as well as strong interpersonal skills.
- Proven ability to work independently and to be able to manage time appropriately
- Strong organizational skills.
- Computer literate. Must be able to pass computer documentation competency testing for all software platforms used within the program. This must occur within 3months of initial training and/or 6 months of hire, whichever comes first.
- Candidates will need a NYS driver's license and to own or have access to reliable transportation that enables them to fulfill travel requirements of the job including but not limited to, daily visits to members' homes.
- Bilingual Candidate Preferred