Care Manager I - HH

Health Home Care Manager

Community Healthcare Network (CHN) is a not-for-profit organization providing more than 65,000 New Yorkers with primary and behavioral healthcare, dental, nutrition, wellness, and needed support services.

Our network is made up of 14 federally qualified health centers throughout Brooklyn, the Bronx, Queens, and Manhattan, along with a fleet of mobile vans that bring health services to underserved people in need throughout New York City. We provide judgment-free, high-quality healthcare, without regard to race, religion, orientation, gender identity, immigration status or ability to pay. We turn no one away.

Growth and development: Access to various healthcare professionals and benefits to deepen understanding and interest in the various disciplines involved in community health programming.

Supportive team culture: Be a part of an interdisciplinary environment where your ideas and work are valued and encouraged.

Comprehensive benefits: Including health, dental and vision insurance, retirement plans, employee assistance programming and more.

Position summary:

The role of Health Home Care Manager (HHCM), primary function is guiding chronically ill patients through the health care system by assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes. The HHCM acts as the team leader, provides direct services to patients including the completion of needs assessments, development of patient focused care plans, periodic reassessments and overall comprehensive service coordination. The HHCM also functions as an advocate for clients within the agency and with external service providers. As a team leader, the HHCM is ultimately responsible for the overall provision and coordination of services to assigned patients.

The HHCM works closely with the patient's Care Team (Provider, medical assistant, nurse, behavioral health provider, social worker, etc.) to coordinate all aspect of care inclusive of appointments, referrals, adherence, specialty care, etc. The HHCM will act as a primary conduit for the transmission of information between providers and patients. The HHCM will coordinate services for all assigned patients who have serious, chronic health problems, persistent mental health conditions, and substance use disorder (SUD). The HHCM will provide advocacy, information, and referral services to patients and families to address their medical and psychosocial needs.

Duties and responsibilities:

Essential functions:

1. Provides direct service to a caseload of approximately 60 patients.
2. Provide patient and family support by way of linkage to community resources.
3. Conducts and documents initial assessments of patients' needs including medical, mental health, substance use and social determinants of health within 60 days of enrollment.
4. Provides crisis intervention and health education services as needed.
5. Develops individualized patient centered plan of care with documented input and approval from other providers and the patient in compliance with Health Home standards.
6. Collaborate with patient and care team to implement plan of care towards achieving goals.
7. Conducts home/field visits and maintains patient contact in accordance with program standards.
8. Coordinates patient services with internal and external service providers through regular care conferencing.
9. Documents all patient related encounters and interventions in patient's chart per established workflow.
10. Update plan of care with outcomes of interventions per established workflow.
11. Assist in coordinating care with pharmacies, managed care organizations (MCOs), hospital discharge planning and other members of patient's care team.
12. Conducts and documents initial comprehensive assessment in accordance with Health Home and State guidelines.

Certificate/license required:

• LPN/MSW/MPH/BA/BS degree is required. Two (2) years experience in care coordination is preferred.

Community Healthcare Network Inc