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See full job description here: The Children's Health Homes of Upstate New York, LLC (CHHUNY) was established to plan for and operate as a Health Home for Children. The Health Home Plus Care Manager provides intensive care coordination services to clients with Serious Mental Illness. The Health Home Plus Care Manager is expected to promote independence and ready their Clients for step down into regular Care Management by assisting clients with understanding and navigating the medical, behavioral and social services systems through the completion of assessments, crisis plans and plan of care. The Health Home Plus Care Manager will engage the Clients in a person centered approach to link clients to necessary supports in the community, including member family support, providers and peer services. Ongoing collaboration with community partners, providers and supports systems is essential to ensure best health care outcomes. Minimum Qualifications: *Education (one of the following): Bachelors degree in a qualifying field. NYS teachers certificate requiring a bachelors degree. NYS licensure and registration as a Registered Nurse and a bachelors degree. Bachelors level education (or higher) in any field with five years of experience working directly with persons with behavioral health diagnoses. Credentialed Alcoholism and Substance Abuse Counselor (CASAC). *Experience (must meet both requirements): Two years of experience providing direct services to individuals with: Serious Mental Illness (SMI). Developmental disabilities. Alcoholism or substance abuse. OR two years of experience linking individuals with SMI, developmental disabilities, or alcoholism/substance abuse to community services, such as: Medical, psychiatric, and social services. Educational, legal, housing, and financial service. Note: A masters degree in a relevant field may substitute for one year of experience. Duties: 1. Responsible for, but not limited to comprehensive assessment, outreach and engagement, service and treatment linkages and coordination using evidence-based practices and outcomes. 2. Conduct appropriate screening and either performing or arranging for more detailed assessments when needed (e.g., high-risk substance use or mental health related indicators, harm to self/others, abuse/neglect and domestic violence). 3. Plan and coordinate care management needs for high-need SMI individuals including: o Navigating the mental health service system-including ability to make referrals to mental health housing services, crisis intervention/ diversion, peer support services o Knowledge of the behavioral health managed care benefit package. o Collaborates with inpatient staff and MCO (as applicable) to affect successful transitions out of inpatient or institutional settings. o Addressing the quality, adequacy and continuity of services to ensure appropriate support for individuals mental health and psychosocial needs o Completing plans of care and coordinating with MCOs for HARP members utilizing the Home and Community Based Services (HCBS) benefit package. 4. Maintain engagement with individuals who are often disengaged from care, have difficulty adhering to treatment recommendations, or have a history of homelessness, criminal justice involvement first-episode psychosis and transition-age youth. Key skills and practices to engage high-need SMI individuals include: o Motivational Interviewing o Suicide Prevention o Risk Screening o Trauma Informed Care o Person-centered care planning and interventions o Recovery-Oriented Approaches (e.g., WRAP). 5. Build and use effective communications strategies among peers, medical staff, addiction and mental health providers and other community agencies through the use of electronic assisted devices including Telehealth and other interactive technology.