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 join their team in Manhattan. In this vital role, you will coordinate care for patients with complex medical and psychosocial needs, ensuring they have access to necessary services. You will collaborate with an interdisciplinary team to develop personalized care plans and support patients in overcoming barriers to care. This position offers the chance to make a significant impact on the lives of underserved communities while working in a supportive and dynamic environment. If you are passionate about patient care and have experience in health services, this opportunity is perfect for you.

Qualifications

• 2+ years of experience in care management or related field.
• Strong communication and organizational skills required.

Responsibilities

• Coordinate care for patients with complex medical and psychosocial needs.
• Work with interdisciplinary teams to develop and implement care plans.
• Evaluate medication compliance and assist patients in overcoming barriers.

Skills

Patient Care Coordination

Interdisciplinary Team Collaboration

Medication Management

Barrier Identification and Resolution

Self-Management Education

Education

High School diploma/GED

Bachelor’s degree in Health or Human Services related field

Tools

TREAT system

Job description

Sun River Health provides the highest quality of comprehensive primary, preventative and behavioral health services to all who see it, regardless of insurance status and ability to pay, especially for the underserved and vulnerable. Sun River Health is a Federally Qualified, Non-Profit Health Center serving communities in Suffolk, Rockland, Orange, Dutchess, Ulster, Sullivan, Columbia and Westchester County. Sun River Health is currently seeking a Full-time Care Manager to join our team in Manhattan.

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