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Patient Care Navigator -HARP Unit


Hope Care Management

Reports To:

Program Director

Major Functions:

Under general supervision, the Patient Care Navigator assists the Care Coordinator Supervisor and Care Manager in the provision of care management activities to support clients and their families in accessing needed services.  The Patient Care Navigator is primarily responsible for addressing member needs (i.e. appointment monitoring, event notifications), providing care plan updates and conducting outreach to members in between visits. Patient Care Navigators are the cornerstone of care


Specific Duties and Responsibilities:

  • Conducts agency visits to client's providers.

  • Maintains a separate and individual caseload as assigned by Care Manager and/or Care Coordinator Supervisor.

  • Performs BH HCBS reassessments at least annually and when there are a significant change in status for HARP members receiving BH HCBS, and signs the finalized assessment only when finalized assessment is considered valid.

  • Completes the Eligibility Assessment for HARP enrolled individuals who are part of HCMP; and as a best practice for individuals, who are determined to be BH HCBS eligible, completes the CMHA within 30 days of the date the Eligibility Assessment was conducted.

  • Completes the Eligibility Assessment to determine BH HCBS eligibility within 10 days, but not longer than 21 days of an individual´s assignment to the program, and the Assessment and the CMHA within 30 days of the individual´s enrollment.

  • Prepares plans of care (POC) for HARP members receiving BH HCBS that meet the BH HCBS POC requirements established by the Centers for Medicare and Medicaid Services (CMS). HCMP will utilize the NYSDOH has provided a template that includes all the elements required to be in a POC that meets the HCBS requirements established by CMS.

  • Prior to conducting the Eligibility Assessment and the CMHA for an individual flagged as HARP eligible, verifies the member is HARP enrolled through EPACES/EMEDNY. For the purpose of this billing guidance both HARP and HIV SNP plans will be referred to as HARPs. HARP enrolled members will be identified with Restriction Exception (RE) codes H1 (HARP Enrolled w/o BH HCBS) or H4 (SNP HARP Eligible w/o BH HCBS) and enrolled in a CMO.

  • Utilizes approved Health Home assessment tools and Health Information Technology (HIT) to complete initial and annual assessments and to develop an appropriate care plan of service needs.

  • Completes an accurate monthly HML assessment for each assigned member.

  • Provides referrals, develops linkages and follows up on client services including timely documentation in all Electronic Medical Records for corresponding Health Homes.

  • Uses health Information Technology (HIT) dashboards to link services and communicate among care management team, providers, members and their families/caregivers.

  • Conducts member outreach and engagement activities to designated and potential Health Home members, including face-to-face, mail, electronic and telephone contact.

  • Ensures that services provided to each member of his/her caseload meets core values of care management services as set forth in federal guidelines of Affordable Care Act.

  • Assists members in accessing health care and social service systems including arranging for transportation, scheduling and accompanying member to appointments.

  • Helps members in identifying available community-based resources and actively manage appropriate referrals, access, engagement, follow-up and coordination of services.

  • Assists with coordinating members access to individual and family supports and resources including resources relating to housing, management of mental illness, substance abuse disorders, smoking cessation, diabetes, asthma, hypertension, self-help/recovery resources and other services based on individual needs and preferences.

  • Helps members with managing daily routines related to healthcare and incorporating members’ strengths and identifying barriers.

  • Assists with conducting outreach and engagement activities that support continuity of care including reengaging members in care if they miss appointments and/or don’t follow-up on treatment.

  • Performs other duties as requested.



  •  Bachelor's Degree in Human Services or related field such as child and family studies, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreational therapy, rehabilitation, social work, sociology, or speech and hearing; Or, NYS licensure and current registration as a Registered Nurse and a bachelor´s degree; Or, Bachelor´s level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses; Or, Credentialed Alcoholism and Substance Abuse Counselor (CASAC), required.

  • At least two years’ experience in providing direct services to persons with serious mental illness, or developmental disabilities, or alcohol and/or substance use disorders or linking persons who have serious mental illness (SMI) or developmental disabilities or alcohol and/or substance use to a broad range of services essential to successfully living in a community setting (A Master’s degree in a related field may substitute for up to one year of experience).

  • Bilingual Spanish, preferred.



If you are interested in this position, please submit your resume with a cover letter to