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 Townsend location. 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 collaborates with patients, families, providers, and community services to develop and implement individualized care plans, address barriers to care, support transitions after inpatient or emergency care, and document activities and assessments in the TREAT system. Sun River Health is a Federally Qualified, nonprofit health center serving communities in Suffolk, Rockland, Orange, Dutchess, Ulster, Sullivan, Columbia, and Westchester County. Its mission is to increase access to comprehensive primary and preventive health care and improve community health, especially for underserved and vulnerable populations. The organization provides equal employment opportunities and considers reasonable accommodations for applicants and employees with disabilities in accordance with applicable law.
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.
- Collaborate with the interdisciplinary care team, including primary care, mental health, residential services, and substance abuse providers, to develop and coordinate care plans.
- 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 on written individualized care plans.
- Review patient intake assessments and use the results to coordinate care plans, self-management goals, and strategies.
- Identify potential barriers to care with patients, help develop ways to overcome them, 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 ER 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 the ER.
- Help patients keep scheduled appointments and arrange appropriate metabolic and periodic preventive screening in accordance with 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 ensure 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 as needed and in accordance with agency policy.
- Review benefits, entitlements, and housing with patients and families; assist with applications and follow up as needed to ensure services are approved.
- 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
