The Children’s Health Home Program is a NYS initiative that serves children on Medicaid (up to age 21) with complex medical and/or behavioral conditions, and provides coordinated care management services to improve their care and reduce costs.
MAJOR DUTIES & RESPONSIBILITIES:
•Works closely with the child and their caregiver(s) as well as the child’s care team at NAC and in the community.
?Ensures required program enrollment consents are obtained from the caregiver/consenter.
?Completes initial and ongoing needs assessments (Child and Adolescent Needs and Strengths; CANS-NY) to determine the child’s most appropriate level of care management. Enters CANS-NY data into NYS online portal.
?Responsible for the overall creation and management of the child’s Individualized Plan of Care (POC), by working collaboratively with the child and family and the child’s care team. Based on the POC, the Care Manager is able to:
A. Coordinate the enrollee’s provision of services, as per their acuity level.
B. Support adherence to treatment recommendations.
C. In consultation with clinical and health care staff, monitor and evaluate a child’s needs, including prevention and wellness care, conditions affecting the child’s medical and mental health, care transitions, and social and community services where appropriate.
?Meets client contact requirements, including face-to-face visits in the child’s home on a consistent schedule as per the acuity level determined for each child (high, medium, low).
?Meets Care Management documentation requirements in a timely and accurate manner by effectively utilizing designated Care Management Portal (Medicaid Analytics Performance Portal; MAPP) and Electronic Health Records (EHRs) as needed
?Functions as an advocate for clients within the agency and with external service providers.
?Promotes prevention and wellness care linking enrollees with resources and services based on their individual needs and preferences.
?Works with health care staff at the agency and in the community to educate the child/caregiver(s) on care of chronic conditions, importance of immunizations, screening tests and other preventive interventions.
?Helps clients obtain health care services covered by Medicaid or their Managed Care Plan.
?Effectively communicates and shares information with the child and family/caregiver(s) with appropriate consideration for language, literacy and cultural preferences.
?Coordinates and conducts care planning meetings/conferences and serves as an interdisciplinary team member to effectively provide/coordinate comprehensive and holistic care.
Identifies available community-based resources and actively manages appropriate referrals, access, engagement, follow-up and coordination of services.
In the event of hospital admissions, participates actively in the discharge planning process to ensure that the transition home is supported by the provision of necessary services and treatments, all in place at the time of discharge.
Attends and participates in ongoing staff development trainings to enhance skills needed to effectively meet the demands of the Care Manager position.
Ensures child has periodic evaluations and follow up treatment for dental, vision and hearing care, following Medicaid EPSDT guidelines.