When you work for Gateway Hudson Valley, you make a difference in people's lives.

Our Vision: To be a leader in supporting individuals as they strive to achieve a hopeful, satisfying, active, and contributing life.

We offer Medical, Dental, Life Insurance, 403(b) Retirement, Holidays, and generous PTO

POSITION SUMMARY

Health Home Plus (HH+) is an intensive care management program established to provide HH members the intensive services needed to stabilize their health and social service needs in the community. The Health Home Plus Care Manager (case manager) is responsible for the provision of intensive Care Management services to individuals with Severe and Persistent Mental Illness in Ulster County. The Care Manager collaborates with mental health professionals in Ulster County and Managed Care Organizations to connect with and refer recipients of service with vital resources in the community to be successful in reaching goals.

ESSENTIAL RESPONSIBILITIES

Function as a member of the Health Home Plus Care Management team in Ulster County.

• Participate in county-wide care management trainings, case reviews, and utilization reviews.
• Participate in treatment team meetings for the purpose of facilitating Care Management services
• Provide linkage and referral facilitation for services, resources, and tools on behalf of Care Management recipients to support them in achieving their goals
• Provide Person -Centered, comprehensive, accessible services with continuous follow-up
• Conduct comprehensive outreach and follow-up services to facilitate continued engagement with care
• Facilitate smooth transitions in care, including inpatient admissions, discharge and transfer between providers
• Identify and address barriers to accessing consistent care and inform interventions
• Provide regular communication with the care team members to share information and ensure care is relevant and informed
• Plan regular case conferences with relevant care team members
• Develop qualitative care plans based on comprehensive intake assessments, ongoing reassessments, case conferences, and routine contact with network providers
• Monitor and ensure incorporation of care plan goals into all aspects of care
• Prepare and maintain records of individual progress and services performed, reporting changes in the electronic health record
• Abide by HIPAA laws, regulations, and related agency's policies and procedures
• Provide outreach and presentations to key players regarding Care Management services and service utilization
• Travel to clinics throughout Ulster County to meet with individuals, consult with mental health practitioners, and provide services
• Track utilization of services and monitor outcomes of those referrals
• Complete and submit statistical reports and other required program documentation in a timely manner
• Maintain communication and relationships with individuals, outside agencies, referral sources, and other service providers
• Ensure the achievement of program objectives and contract expectations
• Represent the agency's Care Management services on community committees
• Keep abreast of trends, changes, and new developments in the field of Health Home Care Management and other related areas through professional affiliations, community involvement, conferences, and trainings
• Other duties as assigned

REQUIRED QUALIFICATIONS

Education:

1. A bachelor's degree in one of the fields listed below

2. A NYS teacher's certificate for which a bachelor's degree is required

3. NYS licensure and registration as a Registered Nurse and a bachelor's degree

4. A Bachelor's level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses

5. A Credentialed Alcoholism and Substance Abuse Counselor (CASAC)

And

Experience:

Two years of experience:

1. In providing direct services to people with Serious Mental Illness, developmental disabilities, or alcoholism or substance abuse; or

2. In linking individuals with Serious Mental Illness, developmental disabilities, or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services).

A master's degree in one of the listed education fields may be substituted for one year of Experience.

WORKING CONDITIONS

• Must be able to Sit or stand for 8 hours/day
• Must be able to bend down or kneel occasionally (1-2 times/week)
• Must be able to use hands, wrists, and fingers with full range of motion
• May occasionally be required to lift no more than 25 pounds (1-2 times per month)

We are an EEO/AA employer M/F/D/V/SO employer