Health Home Plus Specialist

Saint Barnabas Medical Center•New York, NY

About The Position

The Health Home Plus Specialist provides patient-centered, data-informed care management for an assigned panel of Health Home Plus patients. The role identifies eligible individuals, coordinates medical and social services, supports engagement in care, and addresses barriers to improved health outcomes. It ensures timely assessment, care planning, outreach, documentation, billing, and performance reporting in collaboration with patients, families, providers, and multidisciplinary teams.

Requirements

Bachelor’s degree in human services or a related discipline.
At least two years of case management experience.
Excellent verbal and written communication skills.
Ability to travel to meet patients.
Proficiency with electronic medical records.
Proficiency in Microsoft Excel.

Nice To Haves

Master’s degree.
Prior experience in Health Home care management services.
Bilingual Spanish/English.

Responsibilities

Download and analyze data to identify potential patients, and review charts across multiple systems to determine eligibility for services.
Assess information and conduct telephone and in-person outreach to support patient enrollment, tailoring the approach to each individual.
Complete comprehensive assessments for assigned patients after discussion with the patient or family member and review of medical records; conduct other required assessments.
Complete and maintain patient-centered Plans of Care based on comprehensive assessments, within required timeframes, to address health and social needs.
Provide intensive care management to an assigned panel, meet required contact schedules, and plan encounters to support program compliance.
Help patients secure medical and social service appointments, remind them of pending appointments, and follow up on missed appointments.
Provide specialized health education to help patients maintain optimal health and meet social needs; conduct field visits as needed and assigned.
Participate in case conferences with other case managers, treatment providers, and multidisciplinary team members.
Assess patient eligibility for relevant programs and complete documentation to support access to services; ensure entitlements, insurance, and benefits are in place.
Monitor patients’ progress in using services and referrals, including appointments, treatment, and medication, through telephone and in-person contact.
Conduct outreach and other contact activities to support ongoing engagement in care, close relevant gaps in care, and improve health conditions.
Manage the caseload to maintain billing compliance, analyze lost revenue, and develop approaches to improve future compliance.
Respond to notifications of inpatient admissions or emergency department visits, assess the situation, and provide necessary interventions.
Accurately record all services in the patient’s electronic health record or other relevant electronic system.
Maintain a caseload-tracking tool to manage cases and ensure timely completion of required elements.
Compile weekly and monthly caseload reports for leadership.
Participate in Health Home Plus training to stay current and develop skills as systems change.
Perform other related duties at management’s discretion.
Attend scheduled department and division meetings and participate as appropriate.