Care Manager of Health Home Care Management
About The Position
Sun River Health is a Federally Qualified, non-profit health center serving communities in several New York counties. The Care Manager has day-to-day responsibility for coordinating care team activities for patients with complex medical and psychosocial needs and helping patients access medical and psychosocial services efficiently. The position is full-time and based at the Townsend location in Bronx, NY. The Care Manager collaborates with an interdisciplinary care team to develop and coordinate care plans, supports patient self-management, identifies and addresses barriers to care, and coordinates services across providers. The role also involves helping patients navigate inpatient and emergency department transitions, appointments, preventive screenings, benefits, entitlements, and housing-related applications. The Care Manager documents activities and assessments in the TREAT system.
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
- Coordinate the day-to-day activities of the care team for patients with complex medical and psychosocial needs.
- Work with interdisciplinary providers, including primary care, mental health, residential services, and substance abuse providers, to develop and coordinate care plans.
- Coordinate with the Patient Navigator regarding field activities and the flow of information across the care team.
- Provide input to providers, patients, and families for written individualized care plans.
- Review intake assessments and coordinate completion of care plans, self-management goals, and strategies.
- Identify potential barriers to care with patients and help them address barriers or adjust treatment goals.
- Evaluate medication compliance, assess barriers to adherence, and ensure medication reconciliation is current.
- Receive 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 inpatient or emergency room discharge.
- Help patients keep scheduled appointments and arrange metabolic and periodic preventive screenings in accordance with agency policy.
- Facilitate communication about test results between patients and physicians as needed.
- Coordinate services with extended care team providers to ensure implementation of the integrated care plan.
- Review TREAT workload reports 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 on service approvals.
- Use the TREAT system to complete documentation and assessments on time, including scheduling activities.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
