Care Manager of Health Home Care Management
About The Position
Sun River Health is seeking a full-time Care Manager in Bronx, NY, at The Hub location. The Care Manager coordinates day-to-day care-team activities for patients with complex medical and psychosocial needs and facilitates their access to medical and psychosocial services efficiently and effectively. The role works with patients, families, providers, and the interdisciplinary care team to develop, implement, and monitor individualized care plans; address barriers to care; support medication adherence; coordinate transitions after hospital or emergency-room visits; and connect patients with appropriate services and resources. The Care Manager also documents assessments and activities in the TREAT system. The minimum education requirement is a high school diploma or GED, with two years of related work experience. A bachelor’s degree in a health- or human-services-related field is preferred.
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 care team’s day-to-day activities for patients with complex medical and psychosocial needs.
- Work with the interdisciplinary care team, including primary care, mental health, residential services, and substance-use 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; contact patients who have not met treatment goals and 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 an emergency room.
- Help patients keep scheduled appointments and arrange metabolic and periodic preventive screenings according to 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 TREAT workload reports to identify patients needing assessment, 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 TREAT to complete documentation and assessments on time, including scheduling activities.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
