Care Manager I - HH

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:

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.

JOB FUNCTION:

Responsibilities include, but are not limited to:

• Provides direct service to a caseload of 50-55 patients with the assistance of a patient navigator.
• Screens for functional scale eligibility, conducts initial assessments, and periodic reassessments of patients' needs including medical, mental heath, substance use, financial, housing and support needs.
• Provides crisis intervention and health education services as needed.
• Develops patient focused care plans with documented input and approval from other providers and the patient in compliance with Health Home standards. .
• Work with the medical staff to develop, implement, and coordinate the care plan for patients with chronic diseases, such as diabetes, asthma, congestive heart failure, hypertension, mental health condition, and substance abuse etc, based on the Health Home chronic disease care coordination model standards.
• Conducts home/field visits and maintains patient contact in accordance with program standards.
• Coordinates patient services with internal and external service providers through regular case conferencing.
• Ensures appropriate record documentation from all members of the case management team.
• Documents the outcomes of care plans in the case record.
• Assist in coordinating care with pharmacies, insurance companies, hospital discharge planning and other providers in the Network.
• Facilitates related services for health center patients as appropriate with respect to their confidentiality and privacy.
• Ability to handle protected health information (PHI) in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Perform other duties as assigned.

WHAT WE LOOK FOR :

• BA/BS Degree is required OR AA/AS Degree or equivalent of college credits from an accredited college/university with four (4) years experience in care coordination required.
• MSW/MPH preferred.
• Two (2) years experience in care coordination is preferred.