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

FreedomCare•New York City, NY

1d•Hybrid

About The Position

FreedomCare is a healthcare company dedicated to revolutionizing the home care industry. We support patients by enabling them to choose their own caregiver to provide care in their homes. Our mission extends across the U.S. We are seeking a Health Home Care Manager to join our Care Management team. This is a field-based position requiring frequent travel to patients' homes in Manhattan and the Bronx, New York. The Health Home Care Manager will outreach and engage potentially eligible patients, obtain consents for enrollment in the Health Home Care Management Program, and then collaborate with the patient's care team to complete comprehensive assessments and patient-centered care plans. Care will be coordinated based on these plans.

Requirements

Associate's degree is a must.
2 years of Care Management experience.
Must be able to travel to a minimum of 2 boroughs - Bronx and Manhattan.
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.
Ability to relate to patients, their families, and community care providers.
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.
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.
Document all services in accordance with Health Homes standards.
Maintain patient confidentiality at all times.