HARP Care Manager
The role of the Health Homes HARP Care Manager, is guiding chronically ill patients through the health care system by assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes.
The Health Homes HARP Care Manager (HCM) acts as the team provides direct services to patients including the completion of Comprehensive assessments, development of patient focused care plans, periodic reassessments and overall comprehensive service coordination.
The HCM functions as an advocate for patients within the agency and with external service providers.
The HCM is ultimately responsible for the overall provision and coordination of services for assigned patients on their caseload.
The role of Health Home HCM is to also assist the Care Team (Provider, Medical Assistant, Nurse, Behavioral Health Provider, Social Worker etc.
) by coordinating all aspect of care inclusive of appointments, referrals, adherence, specialty care, etc.
The HCM will act as a primary conduit for the transmission of information between providers and patients.
The HCM will coordinate services for all patients who have serious, chronic health problems, persistent MH conditions, and those that are actively using substances.
The HCM will provide advocacy, information, and referral services to patients and families to address their medical and psychosocial needs.
POSITION DESCRIPTION:
o Provides direct service consistent with NYSDOH regulations for Health Homes.
o Screens for functional scale eligibility, conducts initial assessments, and periodic reassessments of patients' needs including medical, mental health, substance use, financial, housing and support needs.
o Provides crisis intervention and health education services as needed.
o Develops patient focused care plans with documented input and approval from other providers, and the patient in compliance with Health Home standards.
o Work with the medical staff to develop, implement, and coordinate the care plan for patients with chronic diseases, such as diabetes, asthma, congestive heart failure, hypertension, mental health condition, and substance abuse etc.
, based on the Health Home chronic disease care coordination model standards.
o Conducts home/field visits and maintains patient contact in accordance with program standards.
o Coordinates patient services with internal and external service providers through regular case conferencing.
o Ensures appropriate record documentation in accordance with BAHN requirement and VIP standards.
o Documents the outcomes of care plans in the case record.
o Assist in coordinating care with pharmacies, insurance companies, hospital discharge planning and other providers in the Network.
o Ensures that information sharing is timely, and that it goes when and where it is needed.
o Reviews providers' schedules and individual patients' charts, to assist the care team in coordination of care for current and future visits.
o Handles appointments and non-appointment related calls from patients, as well as providers.
o Supports patients and providers in the medication refill processo Uses registry and other care plan information to inform care team members of care plan implementation required for each patient.
o Provide patient with general information on HIV prevention and primary care of their chronic condition(s)o Ensures that all patients are tracked, and data entered into the system for the purpose of follow-up and reporting.
o Ensures that disease and other registry data entry is up to date and use registryreports to organize plan of care for all patients assigned.
o Keep patients informed of progress of scheduled appointmentso Monitor of patients' adherence to their medical appointmentso Uses and updates the directory of resources in the service area to meet basic healthand human needs.
o Act as a back-up to other Health Homes HARP Care Managers or to other Care Team members as needed.
o Ability to handle protected health information (PHI) in a manner consistent withthe Health Insurance Portability and Accountability Act of 1996 (HIPAA).
o Perform other related duties as assigned.
OTHER FUNCTIONS:
o Special projects as assigned by the Health Home Manager/and other Executive Staff.
o Participates in designated program meetings.
o Participates in staff meetings.
o Participates in relevant internal and external training.
PM20 POSITION QUALIFICATIONS AND COMPETENCIES:
o BA/BS Degree is required.
o Uniformed Assessment System (UAS) access required o Two (2) years' experience in care coordination preferred o Bilingual English/Spanish Preferred.
KNOWLEDGE, SKILLS AND ABILITIES REQUIREDo Good verbal and written communication skills.
o Demonstrated ability to work effectively in a team environment.
o Effective interpersonal relationship and customer service skills.
o Good organizational and time management skillso Good working knowledge of local social service resources or skills to acquire and use this knowledge and information expeditiously.
o Ability to work effectively with people from diverse cultures and diverse socioeconomic situations.
o Computer literate and working knowledge of Microsoft Office (Word, Excel) and Electronic Health Record Systems o Knowledge of HIV/AIDS, chronic medical conditions, mental illness, substance use, and homelessness.
o Knowledge of City, State, and Federal entitlement systems is helpful.
o Demonstrated problem solving skills in a complex environment.
o Ability to work effectively with people from diverse cultures and diverse socioeconomic situations.
PI227232547 Recommended Skills Assessments Behavioral Medicine Care Coordination Communication Computer Literacy Congestive Heart Failure Estimated Salary: $20 to $28 per hour based on qualifications.
The Health Homes HARP Care Manager (HCM) acts as the team provides direct services to patients including the completion of Comprehensive assessments, development of patient focused care plans, periodic reassessments and overall comprehensive service coordination.
The HCM functions as an advocate for patients within the agency and with external service providers.
The HCM is ultimately responsible for the overall provision and coordination of services for assigned patients on their caseload.
The role of Health Home HCM is to also assist the Care Team (Provider, Medical Assistant, Nurse, Behavioral Health Provider, Social Worker etc.
) by coordinating all aspect of care inclusive of appointments, referrals, adherence, specialty care, etc.
The HCM will act as a primary conduit for the transmission of information between providers and patients.
The HCM will coordinate services for all patients who have serious, chronic health problems, persistent MH conditions, and those that are actively using substances.
The HCM will provide advocacy, information, and referral services to patients and families to address their medical and psychosocial needs.
POSITION DESCRIPTION:
o Provides direct service consistent with NYSDOH regulations for Health Homes.
o Screens for functional scale eligibility, conducts initial assessments, and periodic reassessments of patients' needs including medical, mental health, substance use, financial, housing and support needs.
o Provides crisis intervention and health education services as needed.
o Develops patient focused care plans with documented input and approval from other providers, and the patient in compliance with Health Home standards.
o Work with the medical staff to develop, implement, and coordinate the care plan for patients with chronic diseases, such as diabetes, asthma, congestive heart failure, hypertension, mental health condition, and substance abuse etc.
, based on the Health Home chronic disease care coordination model standards.
o Conducts home/field visits and maintains patient contact in accordance with program standards.
o Coordinates patient services with internal and external service providers through regular case conferencing.
o Ensures appropriate record documentation in accordance with BAHN requirement and VIP standards.
o Documents the outcomes of care plans in the case record.
o Assist in coordinating care with pharmacies, insurance companies, hospital discharge planning and other providers in the Network.
o Ensures that information sharing is timely, and that it goes when and where it is needed.
o Reviews providers' schedules and individual patients' charts, to assist the care team in coordination of care for current and future visits.
o Handles appointments and non-appointment related calls from patients, as well as providers.
o Supports patients and providers in the medication refill processo Uses registry and other care plan information to inform care team members of care plan implementation required for each patient.
o Provide patient with general information on HIV prevention and primary care of their chronic condition(s)o Ensures that all patients are tracked, and data entered into the system for the purpose of follow-up and reporting.
o Ensures that disease and other registry data entry is up to date and use registryreports to organize plan of care for all patients assigned.
o Keep patients informed of progress of scheduled appointmentso Monitor of patients' adherence to their medical appointmentso Uses and updates the directory of resources in the service area to meet basic healthand human needs.
o Act as a back-up to other Health Homes HARP Care Managers or to other Care Team members as needed.
o Ability to handle protected health information (PHI) in a manner consistent withthe Health Insurance Portability and Accountability Act of 1996 (HIPAA).
o Perform other related duties as assigned.
OTHER FUNCTIONS:
o Special projects as assigned by the Health Home Manager/and other Executive Staff.
o Participates in designated program meetings.
o Participates in staff meetings.
o Participates in relevant internal and external training.
PM20 POSITION QUALIFICATIONS AND COMPETENCIES:
o BA/BS Degree is required.
o Uniformed Assessment System (UAS) access required o Two (2) years' experience in care coordination preferred o Bilingual English/Spanish Preferred.
KNOWLEDGE, SKILLS AND ABILITIES REQUIREDo Good verbal and written communication skills.
o Demonstrated ability to work effectively in a team environment.
o Effective interpersonal relationship and customer service skills.
o Good organizational and time management skillso Good working knowledge of local social service resources or skills to acquire and use this knowledge and information expeditiously.
o Ability to work effectively with people from diverse cultures and diverse socioeconomic situations.
o Computer literate and working knowledge of Microsoft Office (Word, Excel) and Electronic Health Record Systems o Knowledge of HIV/AIDS, chronic medical conditions, mental illness, substance use, and homelessness.
o Knowledge of City, State, and Federal entitlement systems is helpful.
o Demonstrated problem solving skills in a complex environment.
o Ability to work effectively with people from diverse cultures and diverse socioeconomic situations.
PI227232547 Recommended Skills Assessments Behavioral Medicine Care Coordination Communication Computer Literacy Congestive Heart Failure Estimated Salary: $20 to $28 per hour based on qualifications.
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