On the outside, Trillium Health may look like a neighborhood health center that provides accessible, affordable services to the community. On the inside, we’re focused on caring for all of an individual’s needs. “Extraordinary care, always,” is not just our noble purpose at Trillium Health, it’s our operational system. Our mission targets the complex vulnerabilities of our community, as we address the social, physical, and behavioral needs of those we serve, all under one roof.
Born from the HIV/AIDS epidemic, Trillium Health has grown into a Federally Qualified Health Center (FQHC) Look A-Like, allowing us to expand our reach and serve those who too often face barriers to care. From primary medical care, to LGBTQ affirming care, we are committed to our community. If you are interested in an organization that truly cares, Trillium Health may be for you.
We are currently recruiting for a HARP/HCBS Care Manager.
To provide comprehensive and timely high quality services by directing patient-centered care that will assist in reducing avoidable health care costs and improved patient outcomes by addressing primary medical, specialist and behavioral health care.
Provide client-centered, quality driven, culturally appropriate comprehensive care management to individuals diagnosed with a chronic illness and their families in compliance with agency policies and funder requirements.
Assist in the reduction of avoidable health care cost specifically; (1) preventable hospital admissions/readmissions and (2)avoidable emergency room visits by providing timely post discharge follow-up and improving individual outcomes
Responsible and accountable for coordinating all aspects of the individual’s care
For all HARP enrolled individuals, conduct HARP/HCBS Eligibility Assessment in the Uniform Assessment System (UAS-NY) within the Health Commerce System to determine individual’s eligibility for HCBS Tier 1 and/or Tier 2 services
Identify and review HCBS services with the individual and create an Initial Plan of Care which is inclusive of the individual’s selected HCBS services
Send completed Initial Plan of Care to individual’s Managed Care Organization (MCO) for service approval
Complete applicable documentation for MCO approved HCBS services and send to HCBS providers referred by the MCO
Create a person centered Plan of Care that clearly identifies goals and timeframes for improving the individual’s health and social situation, including interventions that will produce positive outcomes
Submit the Plan of Care utilizing the template provided by the Department of Health to the MCO and approved HCBS service providers
Maintain contact with MCO and HCBS service providers to eliminate barriers related to access to services and to ensure quality service delivery per the individual’s HARP/HCBS Plan of Care
In conjunction with HCBS and all other providers, execute and update the HARP/HCBS Plan of Care for each individual that includes approved HCBS services, community-based and other social supports services in addition to healthcare services that respond to the individual’s needs and preferences and contribute to achieving the individual’s goals
Provide ongoing monitoring of the HARP/HCBS care plan and of each client’s needs, e.g., prevention, wellness, medical, specialist and behavioral health treatment, care transitions and social and community services
Coordinate and provide access to preventive and health promotion services through the Health Home Network, HCBS delivery system and other community resources including prevention of mental illness and substance abuse disorders
Discuss with service providers/clinicians, on an as needed basis, changes in the client’s condition that may necessitate treatment changes (i.e., written orders and/or prescriptions) and provide feedback to practices as feasible and appropriate
Build relationships with the individual and all members of the treatment team to support continuity of care and promote health
Coordinate and participate in regular case review meetings that include all members of the interdisciplinary team
Demonstrate the ability to use the health information technology system to coordinate and link services
Identify available community-based resources and actively manage appropriate referrals, access, engagement, follow-up and coordination of services
Ensure follow-up of tests, treatments, services and referrals incorporated into the client’s plan of care
Accountable for engaging and retaining clients in care
Support adherence to treatment recommendations
Orient clients to services available within the agency and to the mission at Trillium.
Document each client interaction comprehensively and concisely in Netsmart and the individual’s electronic medical record.
Advocate for client access of entitlement programs, treatment facilities, and other needed community services.
Promote client access into internal agency services including, but not limited to: support groups, housing services, daily bread, behavioral wellness, substance use treatment, and medical care.
Demonstrate developing knowledge of community resources.
Demonstrate developing knowledge of HIV/AIDS, Substance Use, Chronic Disease and related issues.
Adhere to all government and funder regulations.
Requires the ability to relate to people of diverse backgrounds, cultures, races, sexual orientations and gender identities or expressions.
Responsible for maintaining confidentiality of all patients, clients, proprietary, and protected information.
Must be proficient in Microsoft Office; Word, Excel, Outlook and Explorer and have the ability to learn and navigate the HIT systems used
Excellent organizational and time management skills required
Must have access to a reliable vehicle and meet the agency driving policy requirements for this position, including a valid NYS driver’s license and proof of required automobile insurance for the vehicle used.
Employees are accountable for meeting performance standards of their departments. They participate in compliance audits and quality improvement plans.
Other duties as assigned.
Bachelor’s degree in health, human or education services and a minimum of two years of qualifying experience including case management or casework with persons who have HIV infection, mental illness, or chemical dependence. Computer proficiency is required. Fluency in Spanish and/or ASL preferred. Must be accustomed to diversity.
While performing the duties of this job the employee is required to stand, sit, walk, use hands to finger, handle, or feel; reach with hands and arms, talk and hear. Occasionally the employee must stoop, bend and lift or move up to 25 lbs. Specific vision abilities required include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.