Care Manager I - HH

Community Healthcare Network•New York, NY

4d•Hybrid

About The Position

The role of Health Home Care Manager (HHCM) primarily functions by guiding chronically ill patients through the healthcare system. This involves assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes. The HHCM acts as a team leader, providing direct services to patients, including conducting needs assessments, developing patient-focused care plans, performing periodic reassessments, and offering comprehensive service coordination. The HHCM also serves as an advocate for clients within the agency and with external service providers. As a team leader, the HHCM is responsible for the overall provision and coordination of services for assigned patients. The HHCM collaborates closely with the patient’s Care Team (Provider, medical assistant, nurse, behavioral health provider, social worker, etc.) to coordinate all aspects of care, including appointments, referrals, adherence, and specialty care. The HHCM acts as a primary conduit for information exchange between providers and patients. The HHCM will coordinate services for all assigned patients with serious, chronic health problems, persistent mental health conditions, and substance use disorder (SUD). The HHCM will provide advocacy, information, and referral services to patients and families to address their medical and psychosocial needs.

Requirements

LPN/MSW/MPH/BA/BS Degree is required.
Proficiency in verbal communication in English.
Demonstrated ability to work effectively in a team environment.
Demonstrated problem solving skills in a complex environment.
Demonstrated effective interpersonal relationship and customer service skills.
Good organizational and time management skills.
Good working knowledge of local social service resources or skills to acquire and use this knowledge and information expeditiously.
Ability to work effectively with people from diverse cultures and diverse socioeconomic situations.
Basic level of skill with Microsoft Word, Excel and ability to use other computer programs and applications (EMRs, etc) in ways that facilitate disease/care coordination management.
Ability to stand, walk or sit for an extended period of time.
Ability to hear within normal range.
Ability to see within normal range.
Excellent verbal and written communications skills.
Ability to deal with agitated patients and staff.
Extended periods of time at a computer.
Finger and hand dexterity to manipulate objects.
Extensive travel on public transportation (only bus & train) to and from sites.
Possible exposure to inclement weather when conducting field work.
Travel to unsafe neighborhoods.
Possible exposure to patients with infectious diseases.
Ability to communicate easily and display a cordial manner towards individuals from a variety of socio-economic, cultural and religious background.
HIPAA, corporate compliance, and Health Home guidelines must be maintained and kept at all times.

Nice To Haves

Two (2) years experience in care coordination is preferred.

Responsibilities

Provides direct service to a caseload of approximately 60 patients.
Provide patient and family support by way of linkage to community resources.
Conducts and documents initial assessments of patients’ needs including medical, mental health, substance use and social determinants of health within 60 days of enrollment.
Provides crisis intervention and health education services as needed.
Develops individualized patient centered plan of care with documented input and approval from other providers and the patient in compliance with Health Home standards.
Collaborate with patient and care team to implement plan of care towards achieving goals.
Conducts home/field visits and maintains patient contact in accordance with program standards.
Coordinates patient services with internal and external service providers through regular care conferencing.
Documents all patient related encounters and interventions in patient’s chart per established workflow.
Update plan of care with outcomes of interventions per established workflow.
Assist in coordinating care with pharmacies, managed care organizations (MCOs), hospital discharge planning and other members of patient’s care team.
Conducts and documents initial comprehensive assessment in accordance with Health Home and State guidelines.
Completes annual reassessment in accordance with Health Home and State guidelines.
Prepares for and facilitates team meetings to delegate plan of care tasks to care team members.
Maintains timely and effective communication with care team regarding all relevant matters pertaining to patient care.
Reviews providers’ schedules and individual patients’ charts, to assist the care team in coordination of care for current and future visits.
Uses registry and other care plan information to inform care team members of care plan implementation required for each patient.
Monitor of patient’s adherence to their medical appointments.
Responds to patient’s complaints and concerns according to CHN and Health Home policy guidelines.
Participate in Quality Assurance (QA) and Quality Initiative (QI) projects.
Develops knowledge and awareness of available community resources in order to assist patients in achieving plan of care goals and addressing social determinants of health.
Provides excellent customer service according to CHN guidelines.
Compliance with Employee Health Services.
Ensures that services provided to patients are appropriate with respect to privacy and confidentiality of protected health information (PHI) in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Provides coverage and support to other care team members as needed or assigned.
Perform other duties as assigned.
Special projects as assigned by the Program Director/VP of HH/VP of Social Services.
Participates in designated program meetings.
Participates in Center staff meetings.
Participates in relevant internal and external training.
Performs other related duties, as assigned.