Care Manager of Health Home Care Management
About The Position
Sun River Health is seeking a full-time Health Home Care Manager to work 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 and an interdisciplinary care team to develop and coordinate individualized care plans, support treatment goals, address barriers to care, and connect patients with appropriate services. The position includes coordinating care transitions after inpatient and emergency-room visits, supporting medication adherence and preventive screening, facilitating communication about test results, and arranging wellness education and other support. The Care Manager documents assessments and activities in the TREAT system. The stated minimum education is a high school diploma or GED, and the minimum related work experience is two years. 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 related work experience.
Nice To Haves
- Bachelor's degree in a health- or human-services-related field.
Responsibilities
- Coordinate development and ongoing implementation of care plans with the interdisciplinary care team, including primary care, mental health, residential services, and substance-abuse providers.
- Work with the Patient Navigator to direct field activity as needed and optimize information flow across the care team.
- Provide input to providers, patients, and families for written individualized care plans.
- Review patient intake assessments and coordinate completion of care plans, self-management goals, and strategies.
- Identify barriers to care with patients, help them develop ways to overcome barriers, and contact patients who have not met treatment goals to address barriers or adjust goals when possible.
- 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 services or an emergency room.
- Help patients keep scheduled appointments and arrange metabolic and periodic preventive screenings in accordance with agency policy.
- Facilitate discussions between patients and physicians as needed so patients and caregivers are aware of test results.
- 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 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 all activity.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
