Children's Care Manager

Overview

SCO Family of Services has provided vital human services throughout New York City and Long Island for more than 100 years. SCO helps vulnerable New Yorkers build a strong foundation for the future. We get young children off to a good start, launch youth into adulthood, stabilize and strengthen families and unlock potential for children and adults with special needs.

SCO Family of Services welcomes you to join our family and help us work together to carry out our mission to build a stronger tomorrow.

The Care Manager serves youth who are enrolled in Medicaid, have two or more chronic conditions, HIV/AIDS, Sickle Cell, Serious Emotional Disturbance (SED), Serious Mental Illness (SMI) or Complex Trauma, ages 0-21 (Children’s Program) & 18 to end of life (Adult Program). The Care Manager plays a critical role in achieving the overall goals for coordination, integration and partnership in the delivery of care to children, adults and families with complex needs.

• Obtain required Care Management enrollment consents from the medical consenter to process enrollment into the Care Management Program.
• Complete initial and ongoing needs assessments such as the Comprehensive Assessment, Child Adolescent Needs and Strengths-New York (CANS-NY) and NYS Eligibility Assessment for HARP.
• Responsible for the development and overall management of the Plan of Care (POC). Through the development of the POC the Care Manager is able to
• Coordinate the member’s provision of services, including providing Care Management Services as identified in the five core services based on the member’s acuity level.
• Support adherence to treatment recommendations and assist/facilitate with referrals, while ensuring follow-through of these referrals.
• Monitor and evaluate a youth’s needs, including but not limited to: 1. Prevention
  2. Wellness 3. Medical
  4. Mental Health
  5. Care Transitions, and 6. Social and Community Services where appropriate.
• Meet the standard billing requirement for each member based on their acuity score. Care Managers should keep in mind that caseloads will most often be “Blended” (Consisting of High, Medium and Low Acuity & Adults and Children (Family Model)).
• Based on acuity level provide the required face-to-face contacts on a consistent schedule as per the Department of Health’s mandates for High, Medium and Low acuity levels.
• Ensure Care Management documentation is completed in a timely and accurate manner by effectively utilizing the daily activity log, and electronic health record.
• Function as an advocate for member within the agency and external service providers.
• Promote wellness and prevention by linking youth with resources and services based on their individual needs and preferences.
• Educate the member/caregiver on Chronic Conditions, Immunizations, Screenings and other preventative interventions.
• Assist the member to obtain and maintain public benefits necessary to gain health care services, including but not limited to: 1. Medicaid
  2. Cash Assistance Eligibility
  3. Social Security
  4. Supplemental Nutrition Assistance Program
  5. Housing 6. Legal Services
  7. Employment and, 8. Training Supports.
• Effectively communicates and shares information with the individual and their families and other caregiver with appropriate consideration for language, literacy, and cultural preferences.
• Conducts care planning meeting/conferences and services and an interdisciplinary team member to effectively provide/coordinate comprehensive and holistic care.
• Identified available community-based resources and actively manages appropriate referrals, access, engagement, follow-up and coordination of services.
• In the event of hospital admissions, actively engages in the discharge planning process ensuring that the patient has recommended post discharge services in place prior to scheduled discharge.
• Attend and participate in ongoing staff development training to enhance skills needed to effectively meet the demands of the Care Manager position.
• Ensure the all members enrolled have periodic evaluations and follow-up treatment for: 1. Dental
  2. Vision and 3. Hearing Care as per the…