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

FreedomCare•New York, NY

7d•$24 - $26•Onsite

About The Position

FreedomCare is a healthcare company dedicated to supporting patients in choosing caregivers who can care for them at home. The Health Home Care Manager works on the Care Management team to engage potentially eligible patients, obtain enrollment consents, and coordinate care for enrolled patients. In collaboration with each patient’s care team, the manager completes comprehensive assessments and patient-centered care plans and coordinates services based on those plans. This is a field-based position requiring frequent travel to patients’ homes in Brooklyn and Queens, New York. The role provides direct care management for a caseload of chronically ill patients, helping them work toward care-plan goals through referrals, access support, connections to community resources, and coordination with healthcare providers and other stakeholders.

Requirements

Associate's degree.
Two years of Care Management experience.
Ability to travel to at least two boroughs, Brooklyn and Queens.
Ability to travel in the field to accompany patients to appointments and meet patients in person when needed.
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.
Strongly preferred: bilingual Spanish.
Ability to travel to all five boroughs in the NYC area.
Strongly preferred: access to a vehicle.

Responsibilities

Screen patients for Health Home functional-scale eligibility and conduct initial assessments and reassessments of 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 service to a caseload of chronically ill patients and help them achieve care-plan goals by facilitating referrals, addressing access issues, connecting them with local resources, and building relationships with healthcare providers.
Coordinate patient services and care with pharmacies, insurance companies, hospital discharge planning, 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.
Outreach to and engage potentially eligible patients and obtain appropriate consents for enrollment in the Health Home Care Management Program.