Health Home Care Manager

• Responsible for comprehensive care management including creating, documenting, executing and updating individualized, patient centered plan of care to integrate continuum of medical, behavioral health services, rehabilitative, long term care and social service needs and clearly identifies the primary care physician/nurse practitioner, specialist(s), behavioral health care provider(s), other providers directly involved in the child’s care.
• Responsible for care coordination and health promotion to engage and retain home health enrollees in care; coordinates and arranges for services; supports adherence to treatment recommendations; monitors and evaluates children’s needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of a plan of care.
• Use Health Information Technology to Input information into health record system to allow for patient’s health information and plan of care to be accessible to multi-disciplinary team of providers including identification of gaps in care including preventive services.
• Follows-up on tests, treatments, services and referrals.
• Responsible for comprehensive transitional care including providing timely access to follow-up care post discharge which includes at a minimum receipt of a summary care record from discharging entity, medication reconciliation, timely scheduled appointments at recommended outpatient providers, and verification with outpatient provider that patient attended the appointment, and a plan to outreach and re-engage patient in care if appointment was missed.
• Identify available community-based resources and actively manage appropriate referrals, access engagement, follow-up and coordination of services.

• Master’s degree with 1 year of experience or Bachelor’s degree with 2 years of experience required or Registered Nurse (RN) with 2 years of experience.
• Must have a valid driver’s license and reliable vehicle.
• Must have a current and valid driver's license with acceptable driving history to the Agency. Travel is required. Ability to coordinate and plan travel for visits and appointments in efficient manner.
• Weekly travel to meet with clients up to one hour away from home office (Albany, NY)
• Ability to work with economically and culturally diverse population.
• Skills: communication skills including written, verbal and listening skills.

• Non-Exempt (Eligible for Overtime) : $22.12/hour to $24.04/hour

Berkshire Farm Center & Services for Youth