Health Home Care Manager/ Pathway of Hope Case manager

Employment Type

: Full-Time


: Healthcare - Allied Health



Care Manager provides outreach and enrollment services to children and adults presumed to meet eligibility requirements of New York State’s Health Home program. They gather assessments and enter documentation that confirms eligibility and identifies areas requiring supportive services. They work with children, adults, families and service providers to create a comprehensive Plan of Health Care, identify additional service providers as necessary, and coordinate the continuing involvement of families and service providers in the execution of the plan.

The Pathway of Hope (POH) Case Manager will be responsible for the provision of intensive case management services to families with children under the age of 18, who are living in generational/chronic poverty. This is an outreach position working with families in their home and in the community.



Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Health Home Care Manager

  • Document all case activity, including outreach, consent development and assessment, plan development, client progress and transition arrangements.
  • Responsible for a caseload of 20 individual.
  • Responsible for actively pursuing referrals for the program.
  • Administer CANS-NY, updating periodically.
  • Develop a comprehensive, family-driven youth-guided Plan of Health Care.
  • Inventory and coordinate existing services relevant to the Plan of Care, identifying and securing additional services as appropriate.
  • Convene and conduct quarterly meetings to review progress, update POCs, and confirm continuing client eligibility.
  • Provide education to family and child concerning the nature and desired effect of services, along with information concerning conditions being treated.
  • Assist families and children in the acquisition and maintenance of public benefits e.g., financial, educational, social, and community services.
  • Provide Health Home services for children with medium acuity needs, including at least two services per month, with at least one of those conducted face to face.
  • Assure responsible transition of client service into and out of Health Home care, between child and adult health homes, and between inpatient and community care as appropriate.
  • Participate in mandatory and optional training.
  • Participate in supervision.
  • Pathway of Hope Case Management

  • Identify and interact with families and individuals to assess their requirements, find internal and external social services programs that would assist them, assess their most urgent needs, appraise the situation, and listen to the clients’ concerns.
  • Responsible for a caseload of 6-8 families.
  • Develop a detailed plan of action to address identified root causes and needs of eligible clients, set goals and outcomes for said clients, and find necessary resources to meet the goals.
  • Establishing and strengthening solid community collaborations with outside agencies, and serving as a client advocate, enhancing a collaborative relationship to maximize the family’s ability to make informed decisions.
  • Consult with other external agencies to provide support services and resources.
  • Keep comprehensive records of clients’ progress throughout the process, including every call, referral, and home visit to track a family’s success.
  • Input accurate and complete data for all contacts with clients into the social services database and required data tracking into Service Point database. Participate in required social service, counseling, and other appropriate TSA trainings.
  • Stay in touch with clients to ensure the services were beneficial and that their needs are still met after pointing clients in the right direction for services.
  • Maintain confidentiality, respect privacy, and preserve the clients’ routine and independence as much as possible.
  • Recognize spiritual needs of person, refer to the Corps officers (who are ordained ministers of the Salvation Army) for pastoral care as appropriate
  • Coordinate/collaborate with general social services ministry of the Corps, to identify potential families that may be appropriate participants of the pathway of Hope program.
  • Maintain inventory for feeding program and emergency food pantry services that may be needed by POH participants.
  • Coordinate POH services with all seasonal social service programs (Christmas, Thanksgiving, Back to School, Summer Camp, etc.) as requested by Corps Officer and Divisional Headquarters
  • Other Duties: Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice due to business needs.


    • Bachelors Degree in Human/ Services Field
    • Minimum of two years of experience in Social Services Field
    • Relevant experience in serving children and families in child welfare, crisis situations, developmental disabilities, behavioral health, primary health care, or social services
    • Experience coordinating and participating in team settings
    • Solid writing and verbal communication; good documentation skills.
    • Work effectively and knowledgeably across a broad spectrum of cultural, ethnic, and racial communities
    • Ability to work in an effective and focused manner when self-directed and beyond immediate oversight
    • Ability to deliver family-driven, youth-guided services
    • Knowledge of community resources and counseling/social work practices with high risk populations.
    • Requires computer proficiency including word processing skills and the ability to provide culturally competent practice
    • Must have valid driver’s license that meets The Salvation Army insurance requirements
    • Must have regular access to a vehicle to provide home visits and outreach services
    • Provide assistance and /or intervention with children
    • Perform all duties associated with job responsibilities

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