Health Homes Care Manager

Cornerstone Family Healthcare•City of Kingston, NY

18h•Hybrid

About The Position

Cornerstone Family Healthcare is actively recruiting for a Health Homes Care Manager to join our growing team in Kingston. This role involves providing core components of care coordination to individuals with chronic illnesses, including mental health conditions and HIV. Care Managers will manage a dedicated caseload of clients, with the caseload size varying based on client needs. A county office will serve as the primary work location, with travel to other locations required.

Requirements

Master’s degree in social work or related degree with some experience in the field; OR bachelor’s degree in social work or related degree with some experience/knowledge in one of the following areas: case management, chemical dependency, mental health, and/or human services; OR LPN with 1 year of experience providing case management or medical coordination among multiple providers.
Computer experience must include Microsoft Word and Excel.
Access to a car and valid driver’s license are also required.

Nice To Haves

Experience with Electronic Health Records (EHR) data entry is a plus.
Bilingual (English/Spanish) is a plus.

Responsibilities

Engage new HH clients into service and maintain engagement in care coordination.
Conduct intake and comprehensive health assessments/reassessments, identifying mental health, chemical dependency and social service needs.
Develop comprehensive, measureable, goal-oriented care plans in collaboration with interdisciplinary team of external providers. The care plans must clearly identify and integrate the entire continuum of care, addressing all needs identified by the comprehensive assessment.
Advocate and assist clients in obtaining and maintaining entitlements and housing.
Assist and support clients in treatment adherence recommendations, including prevention, wellness, recovery, and care transitions.
Refer and follow-up on referrals for clients to ensure medical stabilization.
Closely coordinate all hospital discharges with hospital or acute care settings to ensure thorough implementation of the discharge plan, and follow-up on recommendations from the ER, hospital or acute care facility.
Assist clients and their families in resolving barriers to obtaining medical services.
Escort clients to appointments when necessary to increase medical adherence.
Conduct home and field visits.
Maintain on-going contact with interdisciplinary team of medical providers, acting as team leader for the client’s care coordination activities.
Provide crisis intervention when required.
Meet and maintain program productivity standards.
Maintain Electronic Health Record and all required electronic data.
Track and maintain a system of patient medical appointments, labs and other critical time-sensitive activities required to maintain the client’s health.
Complete all program standards documentation as required.
Participate in supervision and program review each week.
Attend and participate in monthly department, All Staff and other required meetings.
Be familiar with Cornerstone policies and procedures and the Employee Handbook.
Maintain confidentiality of all aspects of Cornerstone including, but not limited to, patient confidentiality, financials, and employee relations.
Perform other related duties as assigned