Community Health Coach

MJHS; City of Hudson (NY); On-site; USD 55,000 - 75,000; Full time

Job summary

Metropolitan Jewish Health System, Inc. seeks an in-home care manager to conduct visits, assess psychosocial and environmental needs, and coordinate interventions for Medicare/Medicaid members. You will educate members on benefits and connect them with community resources to support independence.

Work with an interdisciplinary team to ensure continuity of care across settings, document findings, and assist with advance directives and POA processes as needed.

Qualifications

• Bachelor’s degree in Social Work, psychology or related health field.
• 1–2 years in long term care, managed care, home care, geriatrics, hospital, or hospice.
• Interdisciplinary service delivery experience preferred.
• Knowledge of Medicare/Medicaid regulations.
• Experience with Social Determinants of Health (SDOH) and Certification.

Responsibilities

• Conduct in-person care management visits to identify needs and interventions in members' homes.
• Educate on covered vs. non-covered benefits and ensure continuity of care.
• Collaborate with the interdisciplinary team and report findings to supervisor.
• Facilitate completion of Advance Directives/POA and document accordingly.

Skills

Social Work Knowledge

Interdisciplinary Team Collaboration

Medicare & Medicaid Regulations

Education

Bachelor’s degree in Social Work, psychology or related health field

Job description

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

Conduct in-person care management visits to identify and provide appropriate interventions based on the psychosocial, environmental, and spiritual needs of the member. Use pre-established criteria & care management scripts to identify Social Determinants of Health (SDOH) needs while in the members’ home, in accordance with departmental workflow.

Provide education on how to access covered and non-covered benefits and ensure continuity of care across all healthcare settings by collaborating with the interdisciplinary team. Utilize benefit structure and community-based resources to address member needs. Educate members on preventative health, quality of life interventions, plan benefits, Advanced Directives/Health Care Proxy/Power of Attorney (POA) and help to facilitate the completion of such documentation. Collaborate with the Primary Care Management, report findings, & submit completed documentation to the Support Staff Supervisor.

• Bachelor’s degree in Social Work, psychology or related health field preferred.
• Minimum 1-2 years of relevant work experience in long term care, managed care, home care, geriatrics, hospital setting, or hospice.
• Prior experience in an interdisciplinary service delivery environment preferred.
• Working knowledge of Medicare and Medicaid regulations.
• Strong background in addressing Social Determinants of Health/Certification.