Health Home Care Manager
About The Position
The Health Home Care Manager provides team-based, patient-centered care coordination for people with chronic disease, behavioral health needs, and significant barriers to health. The role supports individuals and their support systems in managing healthcare effectively and addressing social determinants of health. The care manager works collaboratively with medical and behavioral health providers and other members of each person’s care team, including housing services, substance use treatment providers, family or caregivers, and community services. Services are provided to Medicaid recipients and people who are not eligible for Medicaid. This is an office- and field-based position in Mt. Vernon, New York, with travel to multiple counties and visits to individuals’ homes and communities. The stated schedule is Monday through Friday, 8:30 a.m. to 5:00 p.m., with flexibility required. The role may require providing 24/7 coverage for individuals on the caseload as needed.
Requirements
- Valid and unrestricted driver’s license.
- Reliable vehicle available for use during the workday.
- Willingness to travel to multiple counties.
- Strong oral and written communication skills, time-management skills, and organizational skills.
- Proficiency with technology and computers, including the internet, email, word processing, spreadsheets, electronic health records, and databases.
- Ability to use technology to communicate professionally and effectively and to organize information.
- Ability to maintain a nonjudgmental disposition when communicating with a diverse population.
- Ability to work independently and as part of a collaborative team.
- Sensitivity to cultural diversity and trauma-informed care principles.
- Demonstrated ability to connect clients with a broad range of services, including medical, psychiatric, legal, and housing services.
- Ability to work by telephone as well as in person.
- One of the following education and experience pathways: a bachelor’s degree in health and human services or a related field; bachelor’s-level education or higher in any field plus five years of experience working directly with people with behavioral health diagnoses; Credentialed Alcoholism and Substance Abuse Counselor (CASAC); or a master’s degree plus one year of experience.
- Physical ability to access all rooms in a two-story home, work in an open-space floor plan, move throughout the workday, and occasionally lift more than 25 pounds.
Nice To Haves
- Bilingual English/Spanish speaking.
Responsibilities
- Coordinate healthcare services and social-determinant-of-health needs; facilitate engagement, follow-up care, and connections.
- Help individuals navigate the healthcare system and collaborate with internal and external providers.
- Track follow-up and outcomes using a caseload log or spreadsheet.
- Maintain pertinent information in the Health Home electronic health record (EHR), including documenting in-person and telephone encounters, care plan goals, progress, and ongoing assessments.
- In consultation with the care team, facilitate treatment plan changes for individuals who are not improving as expected.
- Partner with individuals to design and implement care plan goals that overcome barriers and improve health outcomes.
- Facilitate referrals to services outside the organization, including housing assistance, vocational rehabilitation, mental health services, specialty care, and substance use treatment.
- Educate individuals about illness, preventive measures, and positive lifestyle changes, and motivate them to adhere to necessary treatments.
- Visit individuals in their homes and communities and conduct full intakes for care management services.
- Advocate for individuals’ rights and establish and maintain community resources as needed.
- Provide 24/7 coverage as needed for individuals on the caseload.
- Perform other related duties as assigned.
Benefits
- Benefits package (details not specified).
