Care Manager II - Health Home
Monroe Plan for Medical Care
 Buffalo, NY

Looking for a career change? We are currently looking for experienced and qualified health homes specialists. We offer competitive pay, flexible schedules and great benefits. If you are passionate about helping individuals and working one on one with them, this might be the right fit for you. Our mission encompasses compassion, empowerment and teamwork. We believe if we are supportive and compassionate to our employees, it will spill over to our members.


Provides care management services to specific population eligible for Health Home services. Provides information, referrals, consultation and/or care management on health and psychosocial issues. This position works with substantial independence in the field, with consultation available from Clinical Team Lead and/or Supervisor, as needed.

Essential Function

Care Management

  • Receives referrals of members for Health Home services from internal and external sources.
  • Contacts referral within appropriate timeframe within required time frame.
  • Develops therapeutic relationship with member utilizing person centered interventions based on the member's level of activation and presenting conditions
  • Coordinates services through communication with all identified health and community providers/agencies connected to the member
  • Develops a Person Centered Plan of Care with the member and involved providers.
  • Interviews referrals and their families to collect data, disseminate pre-approved health education information, and administer satisfaction surveys and related evaluative inventories
  • Determines need and makes recommendations for continuation of or change in services
  • Seeks out consultation/information for complex medical, behavioral health or psycho-social, as needed
  • Travels as required for home visits and other community activities


  • Completes all necessary assessments to include, but not limited to the Health Assessment Tool, Patient Activation Measure (PAM), Health Home authorization, HML assessment within regulatory time frames
  • Documentation of a Person-Centered Care Plan, in collaboration with the client and providers
  • Maintains documentation that is thorough, clearly written and reflective of members' plan of care activities. Documentation needs to be completed at minimum 1x/month and more often as contacts and actions occur in the members' case.
  • Documents in electronic record regarding care management/coaching activities and termination as appropriate

Case Review & Collaboration

  • Participates as a member of multi-disciplinary Care Coordination team
  • Prepare for and participate in case review meetings with the Health Home Clinical Lead to share cases, discoveries, concerns and collaborate in the development of plans of action.
  • Presents members for review every 90 days or more often, as condition requires
  • Initiates and facilitates member focused meetings to include the member, community providers and significant others, as identified by member for the purpose of care coordination and establishment of a natural support group
  • Participates in inter-agency teams to enhance the work environment and provision of services for members
  • Participate in community activities to promote health and public awareness using Monroe Plan specified materials.
  • Assists in locating members in the community through home visits and collaboration with known providers.


Position Limitations:

  • Cannot perform any tasks which are governed by license or registration (i.e. cannot answer questions or make recommendations RE diagnosis, medications or treatment).
  • Cannot transport active Monroe Plan members at any time.
  • Cannot perform hands on care.


  • Bachelors Degree in Social Work, Counseling or related field with a minimum of 5 years' experience in a community outreach or equivalent position or a combination of training and education that meets the above knowledge and skill level.
  • Demonstrates ability to respect individual/family diversity and maintain confidentiality.
  • Demonstrates ability to work as a team member.
  • Knowledge of and ability to work collaboratively with providers and county/community health and human services.
  • Ability to demonstrate excellent communication skills both oral and written as well as strong interpersonal skills.
  • Proven ability to work independently and to manage time appropriately
  • Strong organizational skills.
  • Computer literate.
  • Candidates will need a NYS driver's license and to own or have access to reliable transportation that enables them to fulfill travel requirements of the job including but not limited to, daily visits to members' homes.