Key Responsibilities:
- Complete the HCBS Eligibility Assessment for HARP/SNP members in the Uniform Assessment System-New York (UAS-NY) within 60 days of enrollment.
- Ensure all assessments are conducted in compliance with HARP/SNP guidelines, including in-person or telephonic assessments
- Work with the Care Manager (CM) to ensure they understand the assessment results and the member’s HCBS goals.
- Ensure that all HARP-related goals and tasks are included in the member’s Plan of Care (POC)
- Document the member’s decision regarding HCBS/CORE services in FCM encounter notes, HCBS-CORE tab, and POC.
- Update the POC as necessary based on the HCBS or CORE services the member receives, including service frequency, scope, and duration.
- Manage member referrals for HCBS or CORE services, ensure an accurate and timely referral process, documenting the referral
- Coordinate with HCBS providers and MCOs, ensuring the members are offered a choice of providers, and follow up on the referral process to remove any barriers to care.
- Monitor ongoing services and assist members in accessing the full range of HCBS/CORE services they are eligible for.
- Educate members about their HARP/SNP plan and available HCBS/CORE services within 30 days of enrollment.
- Engage members to determine their interest in and eligibility for HCBS/CORE services, providing support throughout the referral and service initiation process.
- Document any changes in member interest regarding HCBS/CORE services, ensuring all updates are reflected in FCM and the Plan of Care.
- Complete annual HCBS Eligibility Assessments for members already receiving HCBS services.
- Ensure the updated eligibility report is uploaded to the HCBS-CORE tab in FCM.
- Coordinate with the MCO to review and approve any necessary changes to the Plan of Care.
Qualifications:
- A Master’s degree in one of the qualifying fields and one (1) year of Experience ; OR
- A Bachelor’s degree in one of the qualifying fields and two (2) years of Experience; OR
- A Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and two (2) years of Experience; OR
- A Bachelor’s degree or higher in ANY field with either: three (3) years of Experience, or two (2) years of experience as a Health Home care manager serving the SMI or SED population
- Clinical Assessment Skills
- Ability to conduct structured assessments using the UAS-NY and interpret findings to determine HCBS/CORE eligibility.
- Familiarity with HARP/SNP, HCBS, CORE, and Medicaid behavioral health services.
- Experience in collaborating with care teams, providers, and managed care organizations (MCOs) to ensure timely and appropriate service delivery
- Ability to engage with members to assess interest, explain services, and support service initiation in a trauma-informed and culturally competent manner
- Excellent verbal and written communication skills for interfacing with members, care managers, MCOs, and service providers
- Ability to troubleshoot and resolve service access barriers and coordinate care transitions.
- Comfortable using electronic health records, care coordination systems (e.g., FCM), and telehealth tools for remote assessments.
- Bilingual in English and Spanish preferred.
CareCollab is a Medicaid care management organization serving high-acuity populations across
New York City, Westchester, and Nassau County. We work with individuals who have complex
medical, behavioral health, and social needs, including serious mental illness, substance use
disorders, chronic conditions, and housing instability.
Through New York’s Health Home program, we provide care coordination services that help
members:
• Access medical and behavioral health care
• Navigate social services and housing resources
• Stay engaged in treatment
• Avoid unnecessary hospitalizations and emergency room visits