Care Manager - Health Homes

POSITION/TITLE: Health Homes Care Manager

SUPERVISED BY: Health Homes Program Manager

JOB DESCRIPTION:

Under the general supervision of the Health Homes Program Manager the Health Homes Care Manager (HHCM) provides comprehensive, person-centered care coordination and case management services for individuals enrolled in the NYS Health Homes program, including those eligible for OMH Health Home Plus (HH ). The HHCM is responsible for coordinating and integrating all aspects of a member’s medical, behavioral health, substance use, and social service needs. Services are delivered in accordance with NYS Health Home Standards of Care and OMH HH requirements, ensuring that care is comprehensive, strength-based, culturally responsive, and recovery-oriented. The HHCM ensures that members receive timely access to services, experience smooth transitions across levels of care, and achieve meaningful progress toward their identified health and wellness goals. The HHCM must be accessible to assigned Health Home members 24/7 for crisis coordination and support.

This is a full-time position with a standard schedule of Monday through Friday, 8:00 AM–4:00 PM.

QUALIFICATIONS FOR THE POSITION:

(Not the Individuals Qualifications)

• Bachelor’s Degree in Health and Human Services or related field.
• 3-5 years experience in Human Service Field, preferably in providing services to individuals with serious mental illness, substance use disorders, chronic medical conditions, or other medically underserved populations.
• Must have and maintain a valid New York State driver’s license
• Working knowledge of NYS Health Homes and/or OMH Health Home Plus (HH ) program standards preferred.
• Ability to engage and support individuals who are ill, disabled, elderly, emotionally distressed, or resistant to care.
• Strong communication, documentation, and organizational skills.
• Ability to work effectively both independently and as part of a multidisciplinary team.
• Must be able to travel throughout Orange County and surrounding areas as needed.
• Bilingual preferred but not required.
• Demonstrated integrity, positive attitude, and mission-driven commitment to supporting HONOR’s values.

JOB DUTIES AND RESPONSIBILITIES:

• Conducts outreach, intake, and engagement activities to enroll eligible members into the Health Home or Health Home Plus program.
• Completes comprehensive assessments and reassessments (including psychosocial, medical, behavioral health, functional, and social needs) and document within required timeframes.
• Identifies Health Home Plus eligibility and ensure enrollment criteria are verified in coordination with OMH-designated requirements.
• Develops, implements, and routinely updates a Comprehensive Person-Centered Care Plan that addresses physical health, behavioral health, substance use, medication adherence and access, housing stability, social supports and community resources, entitlement benefits, food access and transportation.
• For OMH HH members, ensures the Care Plan incorporates risk mitigation, crisis planning, and psychiatric stability goals as defined by OMH guidelines.
• For members enrolled in HH , ensure enhanced care management consistent with OMH HH standards, including:
• Weekly member contact (minimum one face-to-face per month)
• Coordination with behavioral health providers and residential staff
• Monitoring for medication adherence, psychiatric stability, and safety concerns
• Development of crisis prevention and relapse prevention plans
• Coordination with inpatient psychiatric, substance use, and medical providers to facilitate timely transitions of care
• Documentation of all required HH service elements in the designated timeframes
• Collaborate closely with OMH-licensed programs, outpatient clinics, and hospital discharge planners to support continuity of care.
• Establishes measurable goals, interventions, and timeframes, ensuring member participation and consent.
• Coordinates care among primary care, behavioral health, substance use, and specialty providers.
• Facilitates communication and case conferencing among members of the care team (including family/natural supports, as appropriate).
• Facilitates smooth transitions in care during hospital admissions, discharges, or transfers between providers, ensuring appropriate follow-up within required timeframes.
• Provides or arranges crisis intervention support and coordinates with appropriate emergency and community resources as needed.
• Conducts regular contacts and home/community visits per Health Home and HH standards.
• Monitors member progress, service utilization, and changes in clinical or social status.
• Documents all contacts, interventions, and progress notes in designated electronic health record in accordance with HVCC, DOH and OMH documentation standards.
• Ensures that interventions are linked to active health concerns and goals within the member’s care plan.
• Maintains all required forms, consents, releases, and authorizations.
• Adheres to Health Home program performance measures, outcome tracking, and quality improvement initiatives.
• Participates in multidisciplinary case conferences, team meetings, and supervision sessions.
• Maintains up-to-date knowledge of Health Home and HH regulations, workflows, and care management best practices.

Pay: $24.00 per hour

Benefits:

• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Application Question(s):

• Are you available to work a full-time schedule of Monday through Friday, 8:00 AM–4:00 PM?
• Please briefly describe your experience providing care management, case management, or care coordination services in a health, behavioral health, or human services setting.
• Please provide the best email address to contact you.

Education:

• Bachelor's (Required)

License/Certification:

• Driver's License (Required)

Ability to Commute:

• Middletown, NY (Required)

Work Location: In person

Salary : $24