Care Manager of Health Home Care Management

Sun River Health • Peekskill, NY

2d

About The Position

Sun River Health is seeking a full-time Care Manager at its Poughkeepsie Washington Street location in Poughkeepsie, New York. The Care Manager coordinates day-to-day care team activities for patients with complex medical and psychosocial needs and facilitates access to medical and psychosocial services. The role works with patients, families, providers, and an interdisciplinary care team to develop and implement individualized care plans, address barriers to care, support transitions from inpatient and emergency services, and coordinate health and social services. The position requires timely documentation 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 care team activities and work with interdisciplinary providers to develop and maintain patient care plans.
• Coordinate with the Patient Navigator to direct field activity as needed and support 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; follow up with patients who have not met treatment goals and 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 inpatient or emergency room discharge.
• Help patients keep scheduled appointments and arrange appropriate metabolic and periodic preventive screening in accordance with agency policy.
• Facilitate communication between patients and physicians so patients and caregivers are aware of test results.
• Coordinate services between patients and extended care team providers to ensure implementation of integrated care plans.
• Review workload reports in TREAT to identify patients requiring 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 as needed and in accordance with agency policy.
• Review benefits, entitlements, and housing with patients and families; assist with applications and follow up on approvals.
• Use TREAT to complete documentation and assessments on time, including scheduling activities.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED