Health Home Director at People Encouraging People

POSITION OVERVIEW

The Health Home Director is responsible for providing comprehensive, person-centered care coordination services to clients enrolled in the Health Home program. This position ensures that individuals with chronic medical, behavioral health, or social needs receive integrated support, timely referrals, advocacy, and collaboration among service providers. The Care Manager works closely with members, families, community agencies, and healthcare providers to improve health outcomes and overall quality of life.

SPECIFIC RESPONSIBILITIES

· Conduct outreach, intake, and enrollment for eligible Health Home members.

· Complete comprehensive assessments and develop individualized care plans.

· Coordinate medical, behavioral health, and social service needs across multiple providers.

· Monitor members’ progress, update care plans, and adjust interventions as needed.

· Act as the primary point of contact for members, families, and providers, advocate for member needs, ensuring access to appropriate services and supports.

· Provide education on wellness, prevention, and self-management

· Facilitate communication among healthcare providers, community-based organizations, and payers.

· Participate in interdisciplinary team meetings.

· Ensure smooth transitions between levels of care (hospital discharges, residential programs, etc.).

· Maintain accurate and timely records in electronic health systems.

· Ensure all care management activities meet Health Home program standards, state requirements, and organizational policies.

· Track outcomes, quality measures, and service utilization.

· Identify high-risk situations and respond with appropriate interventions.

· Develop safety or crisis plans in collaboration with members and providers.

· Escalate concerns to supervisors or clinical leads when necessary.

EDUCATION, WORK EXPERIENCE AND JOB REQUIREMENTS

Education Requirements: Bachelor’s degree in nursing, or related field.

Experience in case management, care coordination, behavioral health, or community services preferred.

Knowledge of medical, behavioral health, and social service systems. Strong communication, problem-solving, and organizational skills.

Job Requirements:

· Must possess excellent person-centered care, cultural sensitivity, crisis intervention, motivational interviewing, collaboration and relationship building.

· Time management and documentation accuracy.

· Must hold an current Maryland RN or NP license.

· Valid Maryland Driver’s License and access to a personal vehicle.

· Mileage expenses are reimbursable according to agency policy.