Community Health Coach

Metropolitan Jewish Health System, Inc.; New York (NY); On-site; USD 65,000 - 85,000; Full time

Job summary

Metropolitan Jewish Health System, Inc. seeks an experienced care manager to conduct in-person visits for elders and at-risk members, focusing on psychosocial, environmental, and spiritual needs within the home.

You will educate members on benefits, ensure continuity of care across settings, and collaborate with an interdisciplinary team to document and coordinate services with the Support Staff Supervisor.

Qualifications

• 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.

Responsibilities

• Conduct in-person care management visits to assess psychosocial, environmental, and spiritual needs.
• Identify SDOH needs using established criteria and scripts during home visits.
• Educate members on benefits, plan coverage, and continuity of care across settings.
• Collaborate with the interdisciplinary team and report findings to the supervisor.
• Facilitate documentation and completion of required forms (POA, directives).

Skills

Care management

SDOH assessment

Interdisciplinary collaboration

Member education

Documentation

Education

Bachelor's degree in Social Work 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.