Care Manager of Health Home Care Management - Coram
About The Position
Sun River Health is a Federally Qualified, non-profit health center serving communities across several New York counties. The Health Home Care Manager provides care coordination and support to clients with chronic medical and behavioral health conditions affected by social determinants of health, helping them navigate healthcare, community, and social service systems. This is a full-time position located in Coram, New York. The Care Manager works with clients, families, and an interdisciplinary care team to develop and coordinate individualized care plans, address barriers to care, support medication adherence, and arrange health and social services. The role includes care transitions following inpatient and emergency room visits, appointment and screening coordination, patient education, benefits and housing assistance, and timely documentation in the TREAT system. Sun River Health’s mission is to increase access to comprehensive primary and preventive health care and improve the health status of its community, especially underserved and vulnerable populations.
Requirements
- High school diploma or GED.
- At least 2 years of work-related experience.
Nice To Haves
- Bachelor’s degree in a health- or human-services-related field.
Responsibilities
- Work with the interdisciplinary care team, including primary care, mental health, residential services, and substance abuse providers, to develop and coordinate care plans.
- Coordinate with the Patient Navigator on field activity and information flow across the care team.
- Provide input to providers, patients, and families on written individualized care plans.
- Review intake assessments and coordinate completion of care plans, self-management goals, and strategies.
- Identify barriers to care with patients and help them address those barriers; follow up with patients who have not met treatment goals to resolve barriers or adjust goals when possible.
- Evaluate medication compliance, assess barriers to adherence, and ensure medication reconciliation is current.
- Respond to alerts about inpatient and emergency room admissions, visit patients during inpatient stays, and participate in discharge planning and care transitions.
- Contact patients within one business day after discharge from inpatient services or the emergency room.
- Help patients keep scheduled appointments and arrange appropriate metabolic and periodic preventive screenings in accordance with agency policy.
- Ensure patients and caregivers are aware of test results by facilitating discussions with physicians as needed.
- Coordinate services between patients and extended care team providers to support implementation of the integrated care plan.
- Review workload reports in TREAT to identify patients requiring assessments, outreach, and engagement.
- Provide or arrange self-management and wellness education, peer support, and other support groups in the patient’s or family’s preferred language.
- Organize and participate in case conferences according to patient needs and agency policy.
- Review benefits, entitlements, and housing with patients and families; assist with applications and follow up as needed to ensure services are approved.
- Use TREAT to complete documentation and assessments on time, including scheduling all activity.
Benefits
- $1,500 sign-on bonus; terms and conditions apply.
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What This Job Offers
Job Type
Full-time
Education Level
High school or GED
