Health Home Care Manager (Downstate, NY / Field-based)

FreedomCare•New York, NY

7d•$24 - $26•Onsite

About The Position

FreedomCare is seeking a Health Home Care Manager to join its Care Management team. The role engages potentially eligible patients, obtains consent for enrollment in the Health Home Care Management Program, and, after enrollment, works with each patient’s care team to complete a comprehensive assessment, create a patient-centered care plan, and coordinate services according to that plan. This is a field-based position requiring frequent travel to patients’ homes in Queens and Brooklyn, New York. The Care Manager serves a caseload of chronically ill patients and helps them pursue care-plan goals by arranging referrals, addressing barriers to access, connecting patients with community resources, and coordinating with providers and other supports. The role also conducts home visits, documents services in accordance with Health Homes standards, and maintains patient confidentiality.

Requirements

Associate’s degree.
Two years of Care Management experience.
Ability to travel to at least two boroughs: Brooklyn and Queens.
Strong working knowledge of local community resources.
Demonstrated ability to work with data reporting, documentation, and outcomes.
Strong communication and assessment skills, including the ability to relate to patients, families, and community care providers and handle rapidly changing crisis situations.
Ability to manage high-volume caseloads.
Empathy and compassion for underserved populations.
Experience navigating multiple data management systems, such as Salesforce.

Nice To Haves

Bachelor’s degree.
Bilingual Spanish skills are strongly preferred.
Ability to travel to all five boroughs in the NYC area.
Access to a vehicle is strongly preferred.

Responsibilities

Screen patients for Health Home functional scale eligibility and conduct initial assessments and reassessments covering medical, mental health, substance use, financial, housing, and other support needs.
Collaborate with medical providers and patients to develop, implement, and coordinate Health Homes-compliant care plans for patients with chronic conditions, and document care-plan outcomes.
Provide direct services to a caseload of chronically ill patients to help them achieve care-plan goals.
Facilitate referrals, address access issues, connect patients to local resources, and build relationships with healthcare providers.
Coordinate patient services and care with pharmacies, insurance companies, hospital discharge planners, family caregivers, and other providers.
Provide crisis intervention when needed.
Conduct home visits and maintain patient contact and documentation of services in accordance with Health Homes standards.
Maintain patient confidentiality.
Travel in the field to meet patients in person and accompany them to appointments when needed.