CARE HOME MANAGER JOB DESCRIPTION

Care management in community health is not interchangeable with clinical treatment. A Care Home Manager in this sector owns the individual plan of care from first assessment through ongoing service coordination, operating within HIPAA-regulated documentation environments and CANS-NY certification requirements. Caseloads regularly span 10 to 40 enrollees with co-occurring medical and behavioral health diagnoses. That breadth demands both clinical judgment and organizational precision, qualities that distinguish this role from the Health Home Care Coordinator or Case Manager positions it works alongside.

As the Care Home Manager, you carry accountability for the full scope of person-centered care planning, from enrollment and comprehensive assessment through service coordination, treatment adherence monitoring, and care transitions, for a caseload of adults or children with intensive medical and behavioral health needs. The role operates within an interdisciplinary health home team, maintaining compliance with applicable state and federal regulations while serving as the primary liaison among enrollees, families, physicians, and community service providers.

Career Impact: Earning CANS-NY certification and accumulating caseload experience across pediatric and adult behavioral health populations builds the specialized profile required for senior care coordination and program leadership roles.

Business Impact: The individual plan of care you author directly determines whether each enrollee accesses timely specialist, preventive, and community services or falls out of care entirely.

Growth Opportunity: Exposure to interdisciplinary care teams, electronic health record systems, and Continuous Quality Improvement processes expands your competency set toward supervisory and program management tracks within health home networks.

• Conduct comprehensive psycho-social, physical, mental health, and environmental assessments for each enrollee within required timeframes.
• Develop individualized plans of care with measurable goals, intervention timelines, and documented behavioral health and medical priorities.
• Coordinate services across physicians, specialists, community providers, and caregivers to ensure seamless delivery aligned with the enrollee's plan.
• Perform scheduled home and face-to-face visits to evaluate health, housing safety, and service adherence at required frequency.
• Maintain detailed case records, progress notes, and assessment documentation in the electronic health record system within 24 to 48 hours of activity.
• Facilitate regular interdisciplinary case review meetings to align all providers, families, and local supports around current care goals.
• Provide crisis intervention, advocacy, and problem-solving support to enrollees navigating acute episodes or care transitions.
• Monitor ongoing service delivery and modify the plan of care in response to changes in the enrollee's clinical or social circumstances.

• Bachelor's degree in social work, counseling, psychology, or a related human services field, or equivalent work experience.
• 2 or more years of direct service experience with adults or children presenting with mental illness, developmental disabilities, or substance use disorders.
• Working knowledge of HIPAA regulations and their application to case documentation and interdisciplinary communication.
• Demonstrated ability to complete thorough clinical assessments and translate findings into goal-oriented care plans.
• Experience maintaining caseload documentation in an electronic health record system with accuracy and timeliness.
• Strong written and verbal communication skills for conveying complex clinical information to enrollees, families, and professional partners.
• Valid driver's license and access to reliable personal transportation for home and community-based visits.

• Master's degree in social work or a related clinical field, providing eligibility for a reduced experience requirement at hire.
• CANS-NY certification or demonstrated familiarity with standardized behavioral health needs assessment instruments.
• Bilingual proficiency in English and Spanish, supporting engagement with linguistically diverse enrollee populations.
• Experience applying for and maintaining public and private benefits on behalf of functionally impaired or indigent clients.

• Caseload engagement rate, measuring the percentage of enrollees retained in active care month over month.
• Plan of care completion rate within required timeframes, reflecting assessment and documentation discipline.
• Home visit adherence percentage, tracking face-to-face contact against prescribed frequency by acuity tier.
• Progress note submission turnaround, measured against the 24-to-48-hour documentation standard.
• Care transition completion rate, tracking successful discharges from institutional settings to community placement.
• CANS-NY recertification status maintained annually, with exam score at or above the 70% passing threshold.
• Typical tools: Electronic health record platforms (commonly used for care plans, assessments, and progress notes); health information technology systems supporting interdisciplinary collaboration.

• Base Salary Range: $48,000 to $68,000 annually, varying by caseload acuity and region
• Bonus: Annual performance-based bonus of 3% to 6% where offered
• Equity: Not typical for nonprofit or community health settings
• Health Benefits: Medical, dental, and vision coverage; employer contribution varies by organization
• PTO: 15 to 20 days annually, with sick leave provided separately in most states
• Common Perks: Mileage reimbursement, continuing education stipend, CANS-NY training support

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Consistent with federal, state, and local law, all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, or any other protected characteristic. Reasonable accommodations are available to individuals with disabilities throughout the application and employment process upon request. Employment is contingent on successful completion of a background check, which may include criminal history and financial record review. Applicants must be authorized to work in the United States.

The Care Home Manager leads the day-to-day operations of the home and staff team, ensuring the highest standards of care in line with CQC compliance requirements. Reporting to senior leadership and collaborating with staff and external stakeholders, the Care Home Manager ensures each service user's physical, social, and emotional needs are met while upholding their dignity and individuality.

Key Responsibilities

• Manage the day-to-day running of the home and staff team to uphold the highest care standards in line with CQC requirements.
• Maintain occupancy levels within the service.
• Support service users to ensure their physical, social, and emotional needs are met.
• Support the personal development of each service user, treating them as an individual with unique support needs.
• Ensure the dignity and individuality of each service user is respected and that they can exercise choice in all areas of life.
• Work in accordance with the company's vision statement, policies, procedures, and all relevant legislation.

Required Qualifications

• Bachelor's degree or NVQ Level 5 in Health and Social Care or equivalent qualification.
• RMA or NVQ 5 certification required.
• Minimum 2 years of Registered Manager experience.
• Strong knowledge of CQC legislation and compliance requirements.
• Strong planning and organisational skills.
• Good communication skills with staff, service users, and external stakeholders.
• Strong leadership skills with the ability to work effectively as part of a team.

Embedded within the care management team, the Care Home Manager delivers comprehensive psycho-social, physical, and mental health assessments to develop and maintain individualized Community Living Plans for clients in home and facility settings. Working closely with clients, caregivers, physicians, and community service providers, the Care Home Manager coordinates care programs that enable functionally impaired adults to remain safely in their communities.

Core Functions

• Conduct comprehensive assessments and re-assessments of client psycho-social, physical, mental health, environmental, and spiritual needs to develop the Community Living Plan.
• Conduct ongoing client home, acute hospital, and skilled nursing facility visits to review and modify their Community Living Plan.
• Document and update progress notes of all case management activity within 24-48 hours.
• Provide crisis intervention, advocacy, problem-solving, and therapeutic intervention services to clients.
• Evaluate client ability to remain safely at home and coordinate appropriate placement if needed.
• Act as liaison between the client, caregiver, physicians, and community service providers to update, arrange, and monitor care program guidelines.
• Attend and participate in program leadership, research, continuing education, and Care Manager Development Program meetings.
• Participate in and promote ongoing Continuous Quality Improvement efforts.

Qualifications & Experience

• Master's degree in Social Work (M.S.W.).
• Case management experience in the community health care delivery system.
• Minimum 2 years of experience resolving medical and psycho-social problems for functionally impaired adults, including 1 year with mental or behavioral health and substance abuse diagnoses.
• Knowledge of gerontology, family systems, and community resources for older adults and people with disabilities.
• Proficient computer literacy skills for documentation and record-keeping.
• Bilingual language skills.
• Exceptional communication and presentation skills.
• Strong attention to detail and ability to prioritize multiple tasks.

Reporting to the Care Management Team leadership, the Care Home Manager builds caseloads through case finding, screening, enrollment, and regular home visits that connect clients to medical care and essential community services. Partnering with clients, peer networks, and service systems, the Care Home Manager supports access and engagement that drives positive health and housing outcomes for underserved populations.

Primary Duties

• Conduct case finding, screening, recruitment, and engagement of all new health home referrals, including enrollment and disenrollment.
• Encourage client empowerment through peer education and support.
• Assist clients in accessing and negotiating service systems, including translation, treatment plan clarification, and advocacy.
• Perform regular home visits to assess clients' living environments and ensure appropriate housing.
• Build caseloads, re-engage clients lost to contact, and maintain active participation in care and services.
• Complete case record documentation, initial assessments, reassessments, and electronic health record entries.

Skills & Qualifications

• Bachelor's degree in a related field.
• Minimum 1 year of relevant work experience, including experience in a home care or outreach role.
• Solid assessment, clinical, and documentation skills.
• Bilingual in English and Spanish.
• Excellent written and verbal communication skills, with strong attention to detail and organisational ability.
• Patient-oriented with great interpersonal skills.

Sitting at the intersection of legal guardianship and direct social care, the Care Home Manager shapes services for older adults and people with disabilities who have been adjudicated as incapacitated, conducting monthly home visits across service areas and coordinating medical, social, and institutional care. Operating across a culturally diverse and primarily indigent client population, this position works alongside project attorneys and medical staff to safeguard client wellbeing and ensure timely, detailed service coordination.

Duties

• Assess clients and their homes to identify medical, social, and safety needs.
• Monitor services through monthly home visits across all five boroughs.
• Arrange services to address medical and social needs and coordinate institutional discharges to the community.
• Consult with project attorneys and medical staff on routine and end-of-life care decisions.
• Apply for and maintain government and private benefits on behalf of clients.
• Work with clients' families and significant others to support care goals.
• Keep timely and detailed records and share rotating 24-hour emergency phone coverage with the team.

Education & Experience

• Bachelor's degree in social work, counseling, or a related field, with a Master's degree preferred.
• Experience working with elderly individuals or people with developmental disabilities.
• Knowledge of public and private benefits available in the city.
• Experience in applying for and maintaining benefits preferred.
• Demonstrated interest in social justice for underserved populations.
• Strong written and oral communication skills, bilingual English and Spanish preferred.
• Excellent organisational skills and ability to work collaboratively in a team environment.
• Creativity, flexibility, patience, and follow-through.

A key member of the care management team, the Care Home Manager owns a caseload of children under 21 with intensive medical and behavioral health needs, developing person-centered care plans with measurable health improvement targets and coordinating services across medical, behavioral, and community providers. Collaborating across interdisciplinary teams, families, and caregivers, this position ensures Health Home enrollees remain engaged in care and that treatment adherence, transitions, and social services are effectively monitored and evaluated.

Functions

• Complete comprehensive assessments to identify individual medical and behavioral health needs within required timeframes.
• Develop plans of care with clear goals, intervention timelines, and measurable health improvement targets.
• Facilitate interdisciplinary collaboration through regular case review meetings and health information technology tools.
• Deliver developmentally appropriate, strengths-based, family-centered services to children and their caregivers.
• Conduct home and face-to-face visits at required frequency to assess health, safety, and environmental conditions.
• Maintain comprehensive client records in the electronic health record system, including care plans, case notes, and assessments.
• Ensure compliance with all applicable policies, governmental laws, regulations, and guidelines.

Requirements

• Bachelor's degree with 2 years of relevant experience, or Master's degree with 1 year, or RN license with 2 years of relevant experience.
• CANS-NY certification required upon hire, with annual recertification at 70% or higher.
• Relevant experience providing direct services for children with mental illness, developmental disabilities, or substance use disorders.
• Knowledge of HIPAA regulations.
• Proficiency with electronic health record systems for documentation and care coordination.
• Ability to communicate complex clinical information to diverse stakeholders.
• Self-motivated with strong problem-solving, adaptability, and organisational skills.
• Demonstrated leadership ability in managing interdisciplinary teams toward person-centered goals.
• Valid NYS Driver's License and access to reliable personal transportation.