Care Manager of Health Home Care Management
About The Position
Sun River Health is seeking a full-time Care Manager for its Poughkeepsie Washington Street location in Poughkeepsie, New York. The Care Manager has day-to-day responsibility for coordinating care-team activities for patients with complex medical and psychosocial needs and facilitating patients’ access to medical and psychosocial services efficiently and effectively. The role works with patients, families, providers, and interdisciplinary care-team members to develop and coordinate individualized care plans, address barriers to care, support medication adherence, coordinate transitions following inpatient or emergency care, and connect patients with appropriate health, social, and community services. The Care Manager documents assessments and activities in the TREAT system and provides or arranges patient and family education and support.
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 and facilitate access to relevant services.
- Work with interdisciplinary care-team members, including primary care, mental health, residential services, and substance abuse 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 patient intake assessments and coordinate completion of care plans, self-management goals, and strategies.
- Identify barriers to care with patients, help address those barriers, and contact patients who have not met treatment goals to resolve 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.
- Encourage patients to keep appointments and arrange metabolic and periodic preventive screening in accordance with agency policy.
- Help 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 integrated care plans.
- Review TREAT workload reports to identify patients requiring assessment, outreach, and engagement.
- Provide or arrange self-management and wellness education and peer or 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
Mid Level
Education Level
High school or GED
