Health Homes Care Manager
About The Position
Cornerstone Family Healthcare is recruiting a full-time Health Homes Care Manager in Newburgh, NY. Under the supervision of a Program Supervisor, the Care Manager provides core care-coordination services to people with chronic illnesses, including mental health conditions and HIV, across low, intermediate, and high levels of need. The role carries a dedicated caseload that varies according to client needs, and the Care Manager is assigned a county office as a primary office location. The Care Manager engages clients, assesses their needs, and coordinates services through client-centered care plans developed with interdisciplinary teams and external providers. The position includes coordination with medical and community-based services, assistance with treatment, benefits and housing, hospital discharge planning, referrals, crisis intervention, home and field visits, and maintaining required records and productivity standards.
Requirements
- One of the following education and experience pathways: a master’s degree in social work or a related degree with some experience in the field; a bachelor’s degree in social work or a related degree with some experience or knowledge in case management, chemical dependency, mental health, or human services; or an LPN credential with one year of experience providing case management or medical coordination among multiple providers.
- Computer experience that includes Microsoft Word and Excel.
- Access to a car and a valid driver’s license.
Nice To Haves
- Experience with Electronic Health Records (EHR) data entry.
- Bilingual English/Spanish.
Responsibilities
- Engage new Health Home clients and maintain their participation in care coordination.
- Conduct intake and comprehensive health assessments and reassessments, identifying mental health, chemical dependency, and social service needs.
- Develop measurable, goal-oriented care plans with interdisciplinary teams and external providers, integrating the continuum of care and needs identified through assessment.
- Advocate for and assist clients in obtaining and maintaining entitlements and housing.
- Support clients with treatment and adherence recommendations, including prevention, wellness, recovery, and care transitions.
- Refer clients to services and follow up to support medical stabilization.
- Coordinate hospital and acute-care discharges and follow up on discharge plans and recommendations from emergency rooms, hospitals, and acute-care facilities.
- Help clients and families resolve barriers to medical services.
- Escort clients to appointments when necessary to support medical adherence.
- Conduct home and field visits.
- Maintain ongoing contact with medical providers and lead the client’s care-coordination activities.
- Provide crisis intervention when required.
- Meet and maintain program productivity standards.
- Maintain the Electronic Health Record and required electronic data.
- Track appointments, laboratory work, and other time-sensitive activities required to maintain clients’ health.
- Complete required program documentation in accordance with applicable standards.
- Participate in weekly supervision and program reviews.
- Attend and participate in monthly department, All Staff, and other required meetings.
- Follow Cornerstone policies, procedures, and the Employee Handbook.
- Maintain confidentiality, including patient, financial, and employee-relations information.
- Perform other related duties as assigned.
Benefits
- Health benefits
- Retirement plan
- Paid time off
- Sick time
- Flexible spending
- Dependent care
- Paid holidays
