Health Home Care Manager
About The Position
The Health Home Care Manager provides team-based, patient-centered care coordination for individuals with chronic disease, behavioral health needs, and significant barriers to health. The role supports individuals and their support systems in managing healthcare effectively and addresses social determinants of health. Care Managers work collaboratively with individuals’ medical and behavioral health providers and other members of the care team, including housing services, substance use treatment, family or caregivers, and community services. The position serves Medicaid recipients and people who are not eligible for Medicaid, helping them access timely, comprehensive care and pursue personal health and life goals. This is an office- and field-based role located in Mt. Vernon, New York, with travel required to multiple counties. The schedule is Monday through Friday, 8:30 a.m. to 5:00 p.m., with flexibility required. Care Managers may also provide 24/7 coverage as needed for individuals on their caseload.
Requirements
- Meet 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.
- Valid and unrestricted driver’s license.
- Reliable vehicle available for use during the workday.
- Willingness to travel to multiple counties.
- Highly organized, with strong oral and written communication skills.
- Ability to communicate nonjudgmentally with a diverse population.
- Proficiency with technology and computer tools, including the internet, email, word processing, spreadsheets, electronic health records, and databases.
- Ability to use technology to communicate professionally and organize information.
- Strong time-management and organizational skills.
- Comfort working 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 and in person.
- Ability to access all rooms in a two-story home, work in an open-space floor plan, and move throughout the workday.
- Ability to occasionally lift more than 25 pounds.
Nice To Haves
- Bilingual English/Spanish-speaking ability.
Responsibilities
- Coordinate healthcare services and social determinants of health needs.
- Facilitate engagement, follow-up care, and connections to services.
- Help individuals navigate the healthcare system.
- Collaborate with involved providers and care team members, internally and externally.
- Track follow-up and outcomes using a caseload log or Excel spreadsheet.
- Maintain pertinent information in the individual’s Health Home Electronic Health Record (EHR).
- Document in-person and telephone encounters, care plan goals, progress, and ongoing assessments in the record.
- Facilitate treatment plan changes, in consultation with the care team, when individuals are not improving as expected.
- Partner with individuals to design and implement care plan goals that address barriers and improve health outcomes.
- Refer individuals to services outside the organization, including housing assistance, vocational rehabilitation, mental health, specialty care, and substance abuse 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.
- Conduct full intakes for care management services.
- Advocate for individuals’ rights.
- 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
