Care Manager I - HH

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.

Job Function

• 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.
• Works 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.
• Collaborates 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.
• Affords 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).

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.