Health Home Care Manager

ACCES Employment

City of Mount Vernon (NY)

On-site

USD 29,000 - 40,000

Full time

14 days+

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Benefits offered by this job

Benefits package

Job summary

Colonial Group is seeking a Care Manager in Mt. Vernon, NY to provide patient-centered, team-based care coordination for individuals with chronic conditions and social determinants impacting health. Travel and field work are required; a valid driver’s license and reliable vehicle are essential.

The role emphasizes home visits, documentation in EHR, and collaboration with medical and behavioral health providers to improve health outcomes and access to services.

Qualifications

Bachelor’s degree in Health and Human services or related field.
Five years of experience working with persons with behavioral health diagnoses if Bachelor's in health field.
Credentialed Alcoholism and Substance Abuse Counselor (CASAC).
Master’s degree with one year of experience.
Bilingual English/Spanish strongly preferred.

Responsibilities

Manage care coordination related to all health care services and social determinants of health needs.
Facilitate engagement, follow-up care, and connections.
Assist in navigating the healthcare system.
Collaborate with providers internally and externally.
Track follow-up and outcomes using a caseload log/excel.
Document encounters and care plans in the Health Home EHR.
Visit people in their homes and communities.
Provide 24/7 coverage as needed for caseloads.

Skills

Oral communication

Written communication

Organization

Time management

Technology skills

Trauma-informed care

Cultural sensitivity

Independent worker

Collaboration

Care coordination

Education

Bachelor’s degree in Health and Human services or related field

Bachelor’s degree + 5 years with behavioral health

CASAC credential

Master’s degree + 1 year experience

Bilingual English/Spanish

Tools

EHR systems

Job description

Location: Mt. Vernon, NY

Pay Rate: $25.00 per hour + benefits package

Hours: Monday-Friday 8:30AM-5:00PM, Flexibility Required.

Office and Field Based Position. Travel Required

OVERVIEW OF PRIMARY RESPONSIBILITIES

Care management is a promising team-based, patient-centered approach designed to assist individuals and their support systems inmanagingtheir healthcare more effectively.

It encompasses care coordination activities that support all social determinants of health needs.

The care manager is a core member of a collaborative team, including the individual’s medical and behavioral health providers, as well as the larger care team including, but not limited to, housing, substance use treatment, family/care givers, and other community services. The care manager coordinates the care of individuals with chronic disease, behavioral health, and significant barriers to health, by assessing them to receive timely, comprehensive care, and supporting them in achieving their personal health and life goals.

Care managers provide services to individuals who are Medicaid recipients as well as people who are not eligible for Medicaid.

PRIMARY FUNCTIONS

Manage care coordination related to all health care services and social determinants of health needs.
Facilitate engagement, follow-up care, and connections.
Assist in navigating the healthcare system.
Collaborate with all of the involved providers both internally and externally.
Track follow-up and outcomes using a caseload log/excel spreadsheet.
Ensure all pertinent information is included in the individual’s record in the Health Home Electronic Health Record (EHR).
Document all in-person and telephone encounters in the record.
Document care plan goals, progress, and ongoing assessments in the record.
Facilitate treatment plan changes for individuals who are not improving as expected, in consultation with their care team. Work as a partner to design and implement care plan goals to overcome barriers and improve health outcomes.

Facilitate referrals for services outside of the organization (e.g., social services such as housing assistance, vocational rehabilitation, mental health, specialty care, substance abuse treatment).

Educate about illness and positive lifestyle changes and motivate them to adhere to necessary treatments.
Educate on the importance of preventative measures.
Visit people in their homes and communities.
Conduct full intakes for care management services.
Act as an advocate for individual’s rights.
Establish and maintain community resources as needed.
Provide 24/7 coverage as needed for individuals on your caseload.

ADDITIONAL FUNCTIONAL / ORGANIZATIONAL SUPPORT

Perform other related duties as assigned

QUALIFICATIONS AND ATTRIBUTES

Valid and unrestricted driver’s license required.
Required to have a reliable vehicle to use during work day
Must be willing to travel to multiple counties

Highly organized with excellent oral and written communication skills
Ability to maintain a non-judgmental disposition and communication with a diverse population
Effective verbal and written communication skills
Proficient technology and computer skills including internet, email, word processing, spreadsheets, electronic health records, and databases. The ability to use technology to communicate effectively and professionally, and organize information.
Strong communication, time management, and organizational skills.
Comfortable working independently and as part of a collaborative team.
Sensitive to cultural diversity and trauma-informed care principles.
Demonstrated ability to link clients with a broad range of services (medical, psychiatric, legal, housing, etc.).
Ability to work by telephone as well as in person

EDUCATION AND EXPERIENCE

Bachelor’s degree in Health and Human services or related field
or
Bachelor’s level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses
or
Credentialed Alcoholism and Substance Abuse Counselor (CASAC)
or
Master’s degree with one year of experience
Bilingual (English/Spanish speaking) strongly preferred

PHYSICAL CHARACTERISTICS

These physical demands are representative of the physical requirements necessary for an employee to perform the job's essential functions successfully. Reasonable accommodation can be made to enable people with disabilities to perform the described essential functions of the position, which are reviewed in each case.