Care Manager of Health Home Care Management
About The Position
Sun River Health is seeking a full-time Care Manager for its Health Home Care Management team in Queens, NY. The role 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. The Care Manager works with patients, families, providers, and an interdisciplinary care team to develop and coordinate individualized care plans, address barriers to care, support transitions after hospital or emergency room visits, and connect clients with appropriate services and resources. The position uses the TREAT system to document assessments and care-management activity.
Requirements
- High school diploma or GED.
- At least 2 years of work-related experience.
- Ability to perform essential job functions, with or without reasonable accommodation.
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 regarding 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 develop ways to overcome them; follow up when treatment goals are not met and adjust goals when appropriate.
- Evaluate medication compliance, assess barriers to adherence, and ensure medication reconciliation is current.
- Respond to inpatient and emergency room admission alerts; visit patients during inpatient stays and participate in discharge planning and care transitions.
- Contact patients within one business day after discharge from inpatient or emergency room services.
- Help patients keep scheduled appointments and arrange metabolic and periodic preventive screenings in accordance with agency policy.
- Help ensure patients and caregivers are aware of test results by facilitating discussions with physicians when 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 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 based on 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 activity.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
