Children's Health Home Care Manager

2 weeks ago

Pelham, United States Family Services of Westchester Full time

Family Services of Westchester (FSW) provides mental health and social services that strengthen and support families, children and individuals at every stage of their lives. With 50 innovative programs, FSW serves 30,000 individuals annually in Westchester County, New York. Founded in 1954, Family Services of Westchester is a private, nonprofit, non-sectarian social services agency.

**The Children’s Health Home Care Manager provide a wide array of services to individuals age 0 to 21 and their families. The services provided by the Children’s Health Home Care Manager aim to improve the individual member’s health outcomes by partnering with other providers to ensure continuity of care and that individualized services are in place. The Children’s Health Home Care Manager assists members and families in becoming independent, and informed consumers of health and mental health services. Primary responsibilities include assessing the needs of members and their families, developing care plans and engaging members in medical, behavioral health and social services.**

**Duties and Responsibilities**
- Outreach potential health home members and their families to determine eligibility for enrollment
- Complete Children’s Health Home intake with families and individuals determined eligible and interested in receiving services through the Children’s Health Home program
- Conduct assessments to identify Health Home members’ individualized needs related to psychosocial wellbeing, physical health and the social determinants of health; utilize standardized assessment tools; monitor needs on an ongoing basis
- Based on the assessment findings, collaborate with member/family to develop a plan of care
- Engage member/family in the goal setting process and utilize Motivational Interviewing and other techniques to assist in goal achievement
- Coordinate and arrange for the provision of medical, behavioral health and other relevant services
- Accompany member/family to appointments as needed; model and coach on medical/behavioral visit navigation with the aim of empowering Health Home member/family to become independent, effective health care consumers
- Conduct home visits as needed
- Support member/family in adherence to treatment recommendations from medical and behavioral health providers
- Provide psychoeducation using one-on-one teaching, written and printed materials as well as computer and video instruction approved by the primary care team to assist with member/family understanding of physical and behavioral health conditions and treatments
- Actively manage appropriate referrals, access, engagement, follow-up, and coordination of services with community-based providers as well as the school system
- Link member/family to services/resources based on individual needs and preferences
- Promote evidence-based wellness and prevention by providing health education on chronic medical conditions such as diabetes, asthma, hypertension, and HIV/AIDS to improve adherence to prescribed treatment
- Discuss advance directives with member/family
- Retain Health Home member/family in care over time
- Maintain a caseload size that does not fall below the minimum and does not exceed the maximum as specified by New York State guidelines (based on number and acuity)
- Perform duties in accordance with established FSW and lead Health Home policies and procedures, objectives, quality improvement activities, and safety standards
- Travel as required to community-based meetings, medical/behavioral health provider sites and meetings with members/families
- Maintain electronic medical records in compliance with FSW and lead Health Home standards and applicable city, state, and federal laws
- Complete all documentation as required for the Children’s Health Home program on time
- Represent FSW at community health fairs and community outreach activities
- Participates in staff development programs, educational activities, seminars, and training opportunities

**Qualifications**

**EDUCATION**
- Degree in Social Work or social sciences preferred; other degrees with relevant experience will be considered

**SKILLS**
- Fluent in English and Spanish
- Strong interpersonal skills including excellent active listening and clear oral communication skills
- Engaging, warm and caring personality
- Strong customer service, patient-centered orientation
- Empathetic and driven to assist patients
- Passionate about providing high quality care to low-income, under-served individuals and those lacking access to health care
- Able to function effectively as a member of an interdisciplinary team and committed to collaborative team-based care
- Able to navigate healthcare and community settings as well as patients’ natural settings (i.e. place of residence)
- Culturally competent/sensitive (racial, ethnic, linguistic, LGBTQ+, physical ability, etc.) and committed to inclusive, multi-cultural programming
- Comfortable providing direct patient care to

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