Care Manager - HH Plus Program

WHO WE ARE: 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. WHAT WE OFFER: 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: Health Home Plus (HH+) is an intensive care management program established to provide HH members the intensive services needed to stabilize their health and social service needs in the community. HH+ supports persons living with HIV (PLWH) by addressing barriers to positive health outcomes, adhering to HIV care and treatment, and achieving viral suppression.The primary function of health home plus care manager (HHPCM), is guiding identified HH+ patients through the health care system by assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes. The HHPCM acts as the team leader, provides direct services to patients including the completion of needs assessments, development of patient focused plan(s) of care, periodic reassessments and overall comprehensive service coordination. The HHPCM also functions as an advocate for clients within the agency and with external service providers.The HHPCM 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. Linkage and retention in care that leads to the achievement of viral suppression is the primary goal for HIV-positive individuals in HH+ program.The HHPCM will also coordinate services for all assigned patients with serious, chronic health problems, persistent mental health conditions, and substance use disorder (SUD), homelessness, etc. The HHPCM will provide advocacy, information, and referral services to patients and families to address their medical and psychosocial needs. Any identified barriers should be included in the care plan and addressed in collaboration with the client, their provider, and the member’s managed care organization (MCO), when appropriate. As a team leader, the HHCM is ultimately responsible for the overall provision and coordination of services to assigned patients. DUTIES AND RESPONSIBILITIES: Essential Functions: Provides direct service to a caseload of approximately 15-20 patients. Conducts and documents initial comprehensive biopsychosocial assessments of patients’ needs including medical, mental health, substance use and social determinants of health in accordance with Health Home Plus guidelines. Assessments, reassessments, and plan of care updates must be conducted face to face in patients’ place of residence. Provides crisis intervention and health education services as needed. Provides HIV prevention, risk reduction and treatment education. Develops individualized patient centered plan of care with documented input and approval from other providers and the patient in compliance with Health Home standards. Collaborates with patient and care team to implement plan of care towards achieving goals. Conducts home/field visits and maintains contact with pt(s) in accordance with program standards. Coordinates care plan driven services with internal and external service providers through regular care conferencing at the time of reassessment (every 6 months) or whenever there is a significant change in the client’s status. Provides a minimum of four (4) core services per month to each patient two of which must be face to face with patient. Coordinate’s patients’ care activities with pharmacies, managed care organizations (MCOs), hospital discharge planning and other members of patient’s care team as needed. Reviews providers’ schedules and individual patients’ charts, to assist the care team in coordination of care for current and future visits. Uses registry, EHR, HIT systems and other care plan information to inform care team members of care plan implementation required for each patient. Participates in Quality Assurance (QA) and Quality Initiative (QI) projects. EDUCATION AND EXPERIENCE REQUIRED: Masters or Bachelor’s Degree in Human Services, Education, Social Work or Mental Health is required with at least one (1) year of experience working with target populations defined as individuals with HIV, history of mental illness, homelessness or substance abuse. Associates Degree in Health, Human Services, Education, Social Work or Mental Health with at least two (2) years of experience working with target populations defined as individuals with HIV, history of mental illness, homelessness or substance abuse. Community Healthcare Network #J-18808-Ljbffr