I. TITLE: Care Manager – Integrated Care Management

II. SUPERVISOR: Care Manager Supervisor – Integrated Care Management

III. HOURS PER WEEK: 40 (some evenings required)


Bachelor’s of Arts or Science Degree with 2 years of
relevant experience or Master’s Degree with 1 year of
experience. Experience with serving children and families
with special needs. Excellent written, verbal,
communication and organizational skills; experience
providing service coordination and information, linkages
and referrals for community-based services; ability to work
with a multi-disciplinary team; self-management abilities,
including overseeing complete and timely maintenance of
client’s records; valid driver’s license; ability to travel to
community based agency offices, participant’s
communities and homes within assigned catchment area.


The Care Manager is 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.


Provide comprehensive care management which includes six core services:
o Comprehensive care management
o Care Coordination and Health Promotion
o Comprehensive Transitional Care
o Patient and Family Support
o Referral to Community and Social Support Services
o Use of Health Information Technology (HIT) To Link Services• Obtain required Care Management enrollment consents from the individual or legal

• Complete initial and ongoing needs assessments (Child and Adolescent Needs and
Strengths; CANS) to determine the appropriate level of care management.
• Manage the patient’s Individualized Plan of Care
• Meet client contact requirements according to patient/client acuity level (high,
medium, or low)
• Meet Care Management documentation requirements in a timely and accurate manner
• Function as an advocate for clients with agency staff and with external service
• Link enrollees with resources and services based on their individual needs and
• Educate the child/caregiver on the care of chronic conditions, immunizations,
screening and other preventive interventions
• Help clients 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.
• Communicate and share information with the individual client and their
families/caregivers with appropriate consideration to language, literacy and cultural
• Conduct care planning meetings/conferences and serve as part of an interdisciplinary
team member to effectively provide/coordinate comprehensive and holistic care
• Identify available community-based resources and manage referrals to those resources.
Provide access, engagement, coordination and follow-up of services
• In the event of hospital admissions, engage in the discharge planning process ensuring
that the client has all recommended post discharge services in place prior to discharge
• Ensure that child has periodic evaluations and follow up treatment for dental, vision
and hearing care, following Medicaid EPSDT guidelines
• Attend and participate in mandatory trainings and staff development trainings to
enhance skills needed to effectively meet the demands of the Care Manager position
• Abide by the NASW, NYS Justice Center and the SAI Codes of Conduct/Ethics
• Complete all other duties, as requested

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