Job Title:  Health Homes Care Manager

Location:  Utica

Salary:  $20.50 – $22.00 Hourly

CLASSIFICATION: Non-Exempt. Thirty-five-hour (35.00) week; evenings and weekends expected for meetings, workshops, and seminars.



    1. Bachelor’s degree and a minimum of two years’ experience in health, human services, or a related field working with individuals with HIV/AIDS, Hepatitis C (HCV), substance use diagnoses, or other chronic illnesses (diabetes, chronic pain, COPD), etc.
    2. Ability to work with diverse populations.
    3. Sensitivity to HIV/AIDS, chronic illness, LGBTQ issues, ham reduction, and a strong commitment to the mission, vision, and values of ACR health are essential.
    4. Excellent organizational and time management skills.
    1. Good communication, documentation and writing skills.
    2. Computer skills and proficiency in Microsoft Office is a must.
    3. Access to a reliable and insured vehicle is required for necessary travel throughout a multi-county region.

 Primary Responsibilities:

  1. Incorporate best practices regarding confidentiality into all job duties and communications in accordance with Article 27-F and HIPAA, ACR Health policies and procedures and other applicable regulations. Protect agency data in accordance with confidentiality procedures and protocols. Observe and abide by the HIV Confidentiality Law and HIPAA.
  2. Assist clients in mutually assessing immediate and long-range needs and identifying resources to secure needed services.
  3. Develop individual care plans in conjunction with the client and related service providers.
  4. Provide direct access to services through immediate and timely response to client needs and involved service providers.
  5. Services may include coordination of medical, behavioral, legal, social, financial, housing, and other per needs as per assessment and service plan.
  6. Maintain contact to ensure sustaining of motivation, timely acquisition of identified services and on-going assessment.
  7. Maintain complete and accurate statistical information; prepare all required monthly and program reports as assigned; ensure thorough, up to date and complete client records.
  8. Complete/submit all required documentation within designated time frames.
  9. Ensure proactive and productive linkages with area social services providers.
  10. Authorize and arrange for necessary support, medical and stabilizing services for the client to develop and maintain effective health care.
  11. Reduce barriers to services through persistent advocacy efforts and appropriate documentation of service gaps.
  12. Advocate for thorough and responsive services acquisition and for systems development through appropriate documentation of service gaps; represent client when advocacy is necessary.
  13. Develop and maintain working knowledge of all area service providers and client resources; keep abreast of developments in the medical, behavioral, social service, legal and other areas related to client services provision.
  14. Complete all required staff, department, and ACR Health trainings, as well as a minimum of 24 hours annually of professional development trainings and certifications.
  15. Conduct interdisciplinary case conferences semi-annually for enrolled clients.
  16. Conduct home visits on a regular basis. Meet with the client’s support network when appropriate to assess responsiveness of the care plan.
  17. Coordinate services with local provider agencies to ensure comprehensive approach, to include ongoing communication with Hospital Care Workers and Discharge Planners.
  18. Re-evaluate care plan on a regular basis to ensure continuity of services.
  19. Ensure interventions are consistent with identified long/short term goals, care plans and needs assessment. Complete reassessments and modify care plan/goals as appropriate.
  20. Advocate for medical, legal, social, financial, housing, and other services, as appropriate.
  21. Provide crisis intervention when appropriate.
  22. Maintain confidentiality of all clients, peers, and volunteers
  23. Maintain working knowledge of all care management program regulations, policies and procedures, as well as required database and/or EMR documentation requirements.
  24. Attend all required and recommended staff trainings and in-services.
  25. Ability to pass Medicaid fraud background check.
  26. Perform other duties as directed by the Health Homes Manager, Director of Care Management Services, Chief Program Officer and/or the Chief Executive Director.