Company Overview: Founded as an orphanage in 1831, Rising Ground has been at the forefront of evolving community needs. Driven by the belief that each of us can thrive when life has hope and opportunity, Rising Ground provides caring support and proven paths to positive change, helping children, adults, and families rise above adversity, and each year, Rising Ground is a positive force in the lives of more than 25,000 individuals. We do this through 101 programs across 138 sites, throughout New York City and Westchester. Our strong belief and commitment to diversity is shown not just through our work with supported persons but is integral to the building of a strong staff that reflects the communities we serve. Rising Ground is headquartered in downtown Brooklyn.

Care Management is a service model whereby all of an individual's caregivers communicate and interface so that the member's needs are addressed in a comprehensive manner. This is done primarily through a "care manager" who oversees and provides access to all of the services an individual needs to assure that they receive everything necessary to prevent hospitalizations, stay healthy, and maintain stability. The Care Manager is ultimately responsible for the overall provision and coordination of services to assigned caseload. The Care Manager guides program enrollees and their caretakers (legal guardians) through the health care system by assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes.

· Obtains required Care Management enrollment consents from the individual or legal guardian

· Completes initial and ongoing needs assessments (Child and Adolescent Needs and Strengths; CANS) to determine the individual’s most appropriate level of care management

· Responsible for the development and overall management of the patient’s Individualized Plan of Care.

· Support adherence to treatment recommendations

· Monitor and evaluate a patient’s needs, including prevention, wellness, medical, mental health, care transitions, and social and community services where appropriate

· Meets client monthly contact and billing requirements

· Meets Care Management documentation requirements in a timely and accurate manner by effectively utilizing designated Care Management Portal and Electronic Health Records (EHRs)

· Functions as an advocate for clients within the agency and external service providers

· Promotes wellness and prevention by linking enrollees with resources and services based on their individual needs and preferences

· Educate the child/caregiver on care of chronic conditions, immunization, screening and other preventive interventions

· Helps clients to obtain and maintain public benefits necessary to gain health care services, including Medicaid and cash assistance eligibility, Social Security, SNAP, housing, legal services, employment and training supports, and others

· Effectively communicates and shares information with the individual and their families and other caregivers with appropriate consideration for language, literacy and cultural preferences

· 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, actively engages in the discharge planning process ensuring that the patient has all recommended post discharge services in place prior to discharge

· Attends and participates in ongoing staff development trainings to enhance skills needed to effectively meet the demands of the Care Manager position

· Ensure that child has periodic evaluations and follow up treatment for dental, vision and hearing care, following Medicaid EPSDT guidelines

· Other duties as assigned

• Bachelors of Arts or Science with two years’ experience
• Bilingual Spanish is a must
• Relevant expertise and experience in serving children and families in child welfare, developmental disabilities, mental health, healthcare and/or other systems as well as those receiving preventive services
• Experience providing service coordination and information, linkages, and referrals for community-based services
• Excellent writing, communication, and organizational skills
• A passion for serving children and families with special needs
• Ability to travel to community-based agency offices, participant’s communities, and homes within assigned catchment area
• Ability to receive feedback to professionally grow and/or improve
• Proven self-management abilities, including meeting deadlines, ensuring compliance with agency policy and procedures, and overseeing complete and timely maintenance of agency records, in accordance with contractual requirements

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Bronx/Queens/Brooklyn Location

Annual Salary

Bachelors: $50,000.00/annually

Masters: $57,000.00/annually

EQUAL EMPLOYMENT OPPORTUNITY STATEMENT

It is the policy of Rising Ground that the Agency wholly complies with equal treatment of all

employees and applicants for employment without unlawful discrimination as to an individual’s

perceived or actual race, creed, color, national origin, alienate, citizenship status, gender, gender

identity, age, disability, marital status, partnership status, sexual orientation, ethnicity, religion, or

veteran status in all employment decisions, including but not limited to recruitment, hiring,

compensation, training and apprenticeship, promotion, upgrading, demotion, downgrading, transfer, layoff and termination and all other terms and conditions of employment.

By signing below, I acknowledge that I have fully read and understand my expectation to meet the requirements, essential functions, and duties of the position and represent that I am capable of doing so in a satisfactory manner.