Health Home Plus Care Manager

East House is a dedicated non-profit organization committed to supporting individuals on their journey to recovery. We provide comprehensive services, including residential support, counseling, peer support and community outreach to empower individuals to overcome mental health and substance use disorders and lead fulfilling lives. Our mission is to foster a supportive environment that promotes healing and long-term recovery, while upholding our humanistic, optimistic, progressive, and collaborative values rooted in integrity. The Health Home Plus Care Manager partners with individuals living with mental illness, substance use disorders, and physical health challenges to provide comprehensive care management. Core responsibilities include care coordination, health promotion, transitional care, patient and family support, referrals to community resources, and the use of health information technology. The goal is to help individuals improve their health and wellness, live self-directed lives, and work toward their full potential. In compliance with NYS's Pay Transparency Act, the salary range for this position is listed above. East House considers factors such as (but not limited to) scope and responsibilities of the position, candidate's work experience, education/training, key skills, internal peer equity, as well as, market and organizational considerations when extending an offer. The hiring process for this position may require a criminal background check and/or motor vehicle records check. Any verbal or written offer made is contingent on satisfactory results, as determined by Human Resources. ResponsibilitiesDirect Care & Client Services * Provide the six core Health Home services: Comprehensive Care Management, Care Coordination, Health Promotion, Comprehensive Transitional Care, Patient and Family Support, and Referral to Community and Social Supports. * Engage and retain individuals who may be disconnected from care or who have complex needs, including those with histories of homelessness, criminal justice involvement, first-episode psychosis, or transitional-age youth. * Utilize evidence-based practices such as motivational interviewing, suicide-prevention strategies, trauma-informed care, risk screening, and person-centered planning. * Maintain a caseload of up to 20 individuals meeting Health Home Plus criteria. * Conduct comprehensive assessments, screenings, outreach, and engagement activities. * Arrange for additional assessments when needed (e.g., substance use, mental health risk, abuse/neglect, domestic violence). * Navigate the healthcare system effectively, including referrals to housing supports, crisis services, peer support, and other community resources. * Support individuals through coordination of care, advocacy, recovery support, and trauma-informed practices. * Develop, revise, and monitor person-centered Plans of Care in accordance with Health Home and Managed Care Organization requirements. * Facilitate effective transitions of care by collaborating with hospitals, treatment providers, and Managed Care Organizations. * Engage family members, natural supports, and service providers in the care coordination process.Documentation & Compliance * Complete accurate, timely documentation in accordance with organizational, county, Medicaid, Health Home, and OMH regulations. * Maintain secure, confidential handling of protected health information in compliance with HIPAA. * Provide each client with a minimum of four Health Home core services per month, including face-to-face, home-based, and/or telephonic contacts.Management Responsibilities * Maintain organized and accurate case records, reports, and required documentation. * Ensure service quality, continuity of care, and adherence to all program standards. * Participate in scheduled individual supervision (weekly to bi-weekly), monthly clinical supervision, required trainings, and meetings