Care Manager - Health Home

Access: Supports for Living•Middletown, NY

1d•Hybrid

About The Position

Care management is a promising team-based, patient-centered approach designed to assist individuals and their support systems in managing their 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/caregivers, 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.

Requirements

Valid and unrestricted driver’s license
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.
Demonstrated ability to collaborate and communicate effectively in a team setting
Ability to maintain effective and professional relationships
Working knowledge of differential diagnosis of common mental health and/or substance abuse disorders
Ability to work by telephone as well as in person

Nice To Haves

Bilingual (English/Spanish speaking) 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 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 as needed.
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 people on your caseload.
Perform other related duties as assigned