Care Manager of Health Home Care Management

Sun River Health; New York (NY); On-site; Full time

Job summary

An established industry player is seeking a dedicated Care Manager to lead the coordination of care for patients with complex medical needs. This role involves working closely with a multidisciplinary team to develop and implement individualized care plans, ensuring that patients have access to necessary services. The ideal candidate will have a strong background in health or human services, excellent communication skills, and a passion for improving patient outcomes. Join a progressive organization that values teamwork and innovation in healthcare delivery, where your contributions will make a meaningful impact on the lives of those you serve.

Qualifications

• 2 years of experience in care management or related field required.
• Strong communication and coordination skills are essential.

Responsibilities

• Coordinate care plans with interdisciplinary teams for patients.
• Evaluate patient needs and barriers to care for effective management.

Skills

Care Coordination

Patient Advocacy

Communication Skills

Medication Management

Problem Solving

Education

High School diploma/GED

Bachelor’s degree in Health or Human Services

Tools

TREAT system

Job description

The Care Manager has overall day-to-day responsibility for coordinating the activities of the care team for patients with complex medical and psychosocial needs and for facilitating each patient’s access to the full range of medical and psychosocial services in an efficient and effective manner.

Essential Duties and Responsibilities of a Care Manager:

1. Works closely with the interdisciplinary care team including the PCP, mental health provider, residential services, substance abuse provider, etc. in the development and ongoing coordination of the care plan.
2. Works closely with the Patient Navigator to direct field activity as needed and ensure the flow of information across and between the care team is optimized.
3. Provides input to providers/patient/family for written individualized care plans.
4. Reviews patient intake assessments and uses results to coordinate the completion of the care plan, self-management goals and strategies.
5. In conjunction with the patient, identifies potential barriers to care and helps patient identify ways to overcome those barriers; reaches out to patients who have not met treatment goals to resolve barriers/adjust goals when possible.
6. Evaluates medication compliance and assesses potential barriers to adherence; ensures medication reconciliation is current.
7. Receives alerts to inpatient and ER admissions. Visits patients during inpatient stays and participates actively in discharge planning and care transition activities.
8. Contacts patients after discharge from inpatient services and ER within one business day.
9. Reaches out to patients to help them keep scheduled appointment; arranges for appropriate metabolic and periodic preventive screening in accordance with agency policy.
10. Ensures that patients and care givers are aware of test results by facilitating discussions between the patient and physician as necessary.
11. Coordinates services between patient and extended care team providers to ensure that integrated care plan is fully implemented.
12. Regularly reviews workload report in TREAT to identify patients requiring, assessments outreach and engagement.
13. Provides or arranges for provision of self-management/ wellness education, peer and other support groups in the language that the patient/family prefers.
14. Organizes and participates in case conferences as per patient need and in accordance with agency policy.
15. Reviews benefits, entitlements, housing with the patient/family and assists in the application process. Follows up as necessary to ensure services are approved.
16. Utilizes the TREAT system to complete all documentation and assessments timely including scheduling of all activity.

Minimum Education Requirement:

High School diploma/ GED

Preferred Education Requirement:

Bachelor’s degree in Health or Human Services related field

Minimum Work Related Experience:

2 years

Job Type: full-time

Salary: $23.00 - $25.00 per hour