Care Manager of Health Home Care Management

Sun River Health•Bronx, NY

1d•Onsite

About The Position

Sun River Health is seeking a Full-time Care Manager to join our team in the Bronx, NY. The Care Manager is responsible for coordinating the activities of the care team for patients with complex medical and psychosocial needs, facilitating their access to medical and psychosocial services efficiently and effectively. This role is crucial in supporting Sun River Health's mission to provide high-quality, comprehensive primary, preventative, and behavioral health services to all, especially the underserved and vulnerable.

Requirements

High School diploma/ GED
2 years of work-related experience

Nice To Haves

Bachelor’s degree in a health or human services related field

Responsibilities

Works closely with the interdisciplinary care team (PCP, mental health provider, residential services, substance abuse provider, etc.) in the development and ongoing coordination of the care plan.
Works closely with the Patient Navigator to direct field activity and ensure optimized information flow across and between the care team.
Provides input to providers, patients, and families for written individualized care plans.
Reviews patient intake assessments and uses results to coordinate the completion of the care plan and self-management goals and strategies.
Identifies potential barriers to care with the patient and helps them identify ways to overcome them; reaches out to patients who have not met treatment goals to resolve barriers or adjust goals.
Evaluates medication compliance, assesses potential barriers to adherence, and ensures medication reconciliation is current.
Receives alerts for inpatient and ER admissions, visits patients during inpatient stays, and participates in discharge planning and care transition activities.
Contacts patients after discharge from inpatient services and ER within one business day.
Reaches out to patients to help them keep scheduled appointments and arranges for appropriate metabolic and periodic preventive screenings.
Ensures patients and caregivers are aware of test results by facilitating discussions between the patient and physician.
Coordinates services between the patient and extended care team providers to ensure integrated care plan implementation.
Regularly reviews workload reports to identify patients requiring assessments, outreach, and engagement.
Provides or arranges for self-management/wellness education and support groups in the patient/family's preferred language.
Organizes and participates in case conferences as per patient need and agency policy.
Reviews benefits, entitlements, and housing with the patient/family and assists in the application process, following up as necessary.
Utilizes the TREAT system to complete all documentation and assessments timely, including scheduling of all activity.