Responsibilities:

• Comprehensive Care Management which includes: a comprehensive health assessment, care plan development  with goals and objectives that are developed holistically, using a person centered and strength based approach, outreach and engagement to community partners and potential collaborative service providers, identifying and referring client to services linkages that support their goals and objectives, monitoring client progress towards achieves goals and objectives and following up as needed, and reassessment and discharge planning when client health objectives improve to the point that care management services are no longer needed.

• Care Coordination and Health Promotion which includes: managing care plan, coordinating and arranging for the provision of services, supporting treatment recommendations and client health objectives, monitoring client progress towards achieving health objectives and coordinating among engaged service providers to avoid emergency room and inpatient services that can more proactively be met in a primary care setting.

• Comprehensive Transitional Care which includes: monitoring health changes in clients recently discharged from the emergency room or inpatient setting or when changes in residential settings occur and coordinating a collaborative response from engaged service providers to develop responses that seek to improve the clients’ health status and engagement in the recommendations they have received associated with their health goals and objectives.

• Patient and family supports which include developing and supporting a self-directed, culturally sensitive, strength-based, and individualized care plan that supports client wellness goals, sustained self-management, self-help and recovery; supporting the inclusion of family members, caregivers and other important people in the client’s support circle into the care plan and the health objectives.

• Job duties include being responsible for an individual caseload and all documentation requirements that entails having at least monthly face-to-face contact with each client; coordinating client care with multiple providers; attending appointments and organizing case reviews; meeting with clients in the office, in the community and in their homes; and attending agency and community meetings to educate people on the benefits of the program.

• Other mental health case management responsibilities as identified by the supervisor.

• Other responsibilities include:

• Ensures the completion of required documents, their accuracy, and the submission into associated databases is submitted in a timely fashion.

• Participates, engages, listens, and learns in individual and team supervision meetings.

• Evaluates individual position and program operation and communicates identified needs to supervisor.

• Maintains and develops current professional skill-base appropriate to position.

• Completes all program and agency training requirements.

• Represents the agency in the community and maintains relationships with community partners with courtesy and professionalism.

• Supports a culture that prioritizes professionalism, kindness, teamwork, and staff development.

• Fulfills responsibilities as a NYS Mandated Reporter.

• Reviews and adheres to all agency policies and procedures.

• Other assignments and tasks may be added at the discretion of the Supervisor, Manager or Director.