Health Home Care Manager — Care Coordination Lead

Community Healthcare Network; Hempfield Township (Westmoreland County); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Growth opportunities

Supportive team culture

Comprehensive benefits

Job summary

Community Healthcare Network is seeking a Health Home Care Manager (HHCM) to guide chronically ill patients through the health care system, coordinating access to services and developing patient-centered care plans. The HHCM leads the team, conducts assessments, and advocates for clients within the agency and with external providers.

In this role, you will work with a care team to coordinate appointments, referrals, adherence, and specialty care, while maintaining documentation and ensuring

Qualifications

• Bachelor's or Master's degree with 2 years of care coordination experience preferred.
• Associates degree or equivalent with 4 years of care coordination experience.
• Bilingual Spanish is a plus.

Responsibilities

• Provides direct service to a caseload of approximately 60 patients.
• Linkage to community resources and patient/family support.
• Conducts initial assessments of needs including medical, mental health, substance use, and social determinants of health within 60 days of enrollment.
• Provides crisis intervention and health education as needed.
• Develops individualized patient-centered care plans with input from providers and patients.
• Collaborates with patient and care team to implement the plan of care and achieve goals.
• Performs home/field visits and maintains ongoing patient contact per program standards.
• Coordinates services with internal and external providers via regular care conferencing.
• Documents all patient encounters and interventions in the chart per workflow.
• Updates care plans with outcomes of interventions per workflow.
• Assists in coordinating care with pharmacies, MCOs, hospital discharge planning, and care team members.
• Conducts initial comprehensive assessments in line with Health Home and State guidelines.
• Completes annual reassessment as required by Health Home and State guidelines.

Skills

Care coordination

Bilingual Spanish

Education

Bachelor's/Master's Degree in relevant field

Associates Degree or equivalent

Bilingual Spanish (plus)

Job description

Community Healthcare Network is seeking a Health Home Care Manager (HHCM) to guide chronically ill patients through the health care system, coordinating access to services and developing patient-centered care plans. The HHCM leads the team, conducts assessments, and advocates for clients within the agency and with external providers.

In this role, you will work with a care team to coordinate appointments, referrals, adherence, and specialty care, while maintaining documentation and ensuring