Complex Case Manager, Social Services for Homebound Seniors

Essen Medical Associates; New York (NY); On-site; USD 60,000 - 90,000; Full time

Job summary

Essen Health Care, in collaboration with Intention Healthcare, seeks a Complex Case Manager to support high-need, homebound patients within New York. You will partner with primary care teams to identify clinical and social needs, connect patients with resources, and coordinate care transitions from hospital to home.

The CCM role emphasizes direct and indirect patient care, advocacy, and education to improve outcomes for vulnerable populations, including coordination with community services and

Qualifications

• Bachelor's in Social Work, or similar
• 2+ years of experience in health care and/or health-related social work
• Strong customer-service orientation and very good verbal communication skills
• Ability to work independently and exercise judgment with providers, patients, and families/caregivers
• Ability to function in a fast-paced environment and be accountable for high performance
• Solid understanding of health care and health insurance concepts: Medicare, Medicaid, Long Term Care, home health, behavioral health, Advanced directives and hospice care
• Personality traits: curiosity, empathy, persistence

Responsibilities

• Develop rapport with patients and family, conducting frequent check-ins and earning the patient’s trust to be their first call for related health matters
• Occasionally visit patients in their homes for safety assessments, patient education, and addressing social needs
• Perform root-cause analysis of hospitalizations and help the clinical team understand social, behavioral, and family dynamics that affected care so interventions can be improved
• Educate about, refer to, and help patients apply to community resources, city and state programs
• Assist with and facilitate the transition of care from inpatient settings to home
• Address medication adherence and other treatment adherence
• Communicate changes in patient status promptly with the care team
• Work with Administrative staff to provide feedback for improved day-to-day operations

Skills

Verbal communication

Customer service

Independent work

Accountability

Education

Bachelor's in Social Work

Tools

Electronic health records

Excel

Job description

Essen Health Care, in collaboration with Intention Healthcare, seeks a Complex Case Manager to support high-need, homebound patients within New York. You will partner with primary care teams to identify clinical and social needs, connect patients with resources, and coordinate care transitions from hospital to home.

The CCM role emphasizes direct and indirect patient care, advocacy, and education to improve outcomes for vulnerable populations, including coordination with community services and