Community Healthcare Network is seeking for a Full-Time Care Manager/Health Homes Plus who will coordinate services for all assigned patients with serious, chronic health problems, persistent mental health conditions, and substance use disorder (SUD), homelessness, etc. The HHPCM will provide advocacy, information, and referral services to patients and families to address their medical and psychosocial needs. Any identified barriers should be included in the care plan and addressed in collaboration with the client, their provider, and the member's managed care organization (MCO), when appropriate. As a team leader, the HHCM is ultimately responsible for the overall provision and coordination of services to assigned patients. JOB FUNCTION: Responsibilities include, but are not limited to: * Provides direct service to a caseload of approximately 15-20 patients. * Conducts and documents initial comprehensive biopsychosocial assessments of patients' needs including medical, mental health, substance use and social determinants of health in accordance with Health Home Plus guidelines. * Assessments, reassessments, and plan of care updates must be conducted face to face in patients' place of residence. * Provides crisis intervention and health education services as needed. * Provides HIV prevention, risk reduction and treatment education. * Works closely with patient to identify and address barriers to adhering to care. * Develops individualized patient centered plan of care with documented input and approval from other providers and the patient in compliance with Health Home standards. * Collaborates with patient and care team to implement plan of care towards achieving goals. * Conducts home/field visits and maintains contact with pt(s) in accordance with program standards. * Coordinates care plan driven services with internal and external service providers through regular care conferencing at the time of reassessment (every 6 months) or whenever there is a significant change in the client's status. * Provides a minimum of four (4) core services per month to each patient two of which must be face to face with patient. * Documents all patient related encounters and interventions in patient's chart per established workflow. * Coordinate's patients' care activities with pharmacies, managed care organizations (MCOs), hospital discharge planning and other members of patient's care team as needed. * Reviews providers' schedules and individual patients' charts, to assist the care team in coordination of care for current and future visits. * Uses registry, EHR, HIT systems and other care plan information to inform care team members of care plan implementation required for each patient. * Monitors patient's adherence to their medical appointments and retention in care. WHAT WE LOOK FOR: * Masters or Bachelor's Degree in Human Services, Education, Social Work or Mental Health is required with at least one (1) year of experience working with target populations defined as individuals with HIV, history of mental illness, homelessness or substance abuse. * Associates Degree in Health, Human Services, Education, Social Work or Mental Health with at least two (2) years of experience working with target populations defined as individuals with HIV, history of mental illness, homelessness or substance abuse.