Health Home Plus Specialist

The Health Home Plus Specialist provides patient-centered, data-informed care management for an assigned panel of Health Home Plus patients by identifying eligible individuals, coordinating medical and social services, supporting engagement in care, and addressing barriers to improved health outcomes. The role ensures timely assessment, care planning, outreach, documentation, billing, and performance reporting in collaboration with patients, families, providers, and multidisciplinary teams.

1. Downloads and analyzes data to identify potential patients, and reviews charts on multiple systems to determine patient eligibility for services
2. Assesses information and conducts telephone and in-person outreach to drive patient enrollment, using a tailored approach for each individual.
3. Completes a comprehensive assessment for each assigned patient, after discussion with the patient, family member, as well as review of patient’s medical records. Conducts other assessments as required.
4. Completes and maintains patient centered Plans of Care (POC) based on comprehensive assessments, within the required time, to address patient health and social needs.
5. Provides intensive care management to an assigned panel of Health Home Plus patients, meeting the required contacts within the time period. Strategizes and plans encounter scheduling for program compliance.
6. Supports patients to secure medical and social service appointments, reminds patients of pending appointments, and follows up on missed appointments. Provides specialized health education to help the patient maintain optimal health and meet social needs. Conducts field visits as needed and assigned.
7. Participates in case conferences with other case managers, treatment provider, and other members of a multidisciplinary team.
8. Assesses patient eligibility for relevant programs and undertakes relevant documentation to ensure patient access to need services. Ensures entitlements, insurance, and benefits are in place.
9. Monitors clients’ progress in utilizing services and referrals (appointments, treatment, medication, etc.) through telephone and in-person contact.
10. Conducts outreach and other contact activities, as needed, to help the patient remain engaged in care, and close relevant gaps in care. Focuses efforts on improving health conditions.
11. Manages their caseload to ensure a high level of billing compliance, analyzing lost revenue and strategizing approaches for future compliance.
12. Actively looks for and responds to notification of inpatient admissions of emergency department visit to assess the situation and provides necessary interventions.
13. Accurately records all services provided in the patient’s electronic health record or other relevant electronic system, as required.
14. Maintains a caseload-tacking toll to effectively manage all aspects of the case and to ensure timely completion of required elements.
15. Compiles weekly and monthly reports on case load for leadership
16. Actively participates in Health Home Plus training opportunities to stay current and develop skills with the changing systems.
17. Performs other related duties at the discretion of the management
18. Attend scheduled department and division meetings and participate as appropriate.

Education Required:

• Bachelor’s degree in human services/related discipline required.
• Master’s Degree is preferred.

License/Certification/Registration(s): None Required

Experience/Skills:

• A minimum two (2) years’ experience in case management required.
• Prior experience in Health Home care management services
• Excellent communication skills, verbal and written.
• Ability to travel to meet patients.
• Proficiency in Electronic Medical Records
• Proficiency in Microsoft Excel
• Bilingual Spanish/English preferred.