Care Manager, Health Homes (Bronx & Manhattan, NY / Field-based)

FreedomCare•New York, NY

21h•$24 - $26•Hybrid

About The Position

FreedomCare is a healthcare company dedicated to revolutionizing the home care industry since 2016, empowering patients to choose their caregivers. The company supports patients across the U.S. and is driven by values of service, empathy, ownership, integrity, and a positive attitude. This field-based position requires frequent travel to patients' homes in the Bronx and Manhattan, New York. The Health Home Care Manager will outreach and engage eligible patients, enroll them in the Health Home Care Management Program, and collaborate with their care team to complete comprehensive assessments and patient-centered care plans. They will coordinate care based on these plans.

Requirements

Associate's degree is a must
2 years of Care Management experience
Ability to travel in the field to accompany patients to appointments and meet patients in person when needed
Strong working knowledge of local community resources
Demonstrated ability to work with data reporting, documentation, and outcomes
Strong communication and assessment skills; the ability to relate to patients, their families, and community care providers, along with ability to handle rapidly changing crisis situations
Ability to manage high volume caseloads
Able to express empathy and compassion for the underserved
Experience navigating several data management systems, such as Salesforce

Nice To Haves

Bachelor's Degree is a plus
Bilingual Spanish strongly preferred
Access to a vehicle is strongly preferred

Responsibilities

Screen for Health Home functional scale eligibility, conduct initial Health Homes assessments and reassessments of patient needs, including medical, mental health, substance use, financial, housing, and additional support needs.
Collaborate with medical providers and patients to develop, implement, and coordinate Health Homes compliant care plans for patients with chronic diseases, such as diabetes, asthma, congestive heart failure, hypertension, mental health conditions, substance use, and more, and document care plan outcomes.
Provide direct service to a caseload of chronically ill patients and help them achieve their care plan goals by facilitating referrals, addressing access issues, connecting them to local resources, and developing relationships with healthcare providers.
Coordinate patient services and care with pharmacies, insurance companies, hospital discharge planning, family caregivers, and other providers.
Provide crisis intervention when needed.
Conduct home visits and maintain patient contact and documentation of all services in accordance with Health Homes standards.
Maintain patient confidentiality at all times.