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, providing 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 aspects 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.

Duties And Responsibilities

• Provides direct service to a caseload of approximately 60 patients.
• Provides patient and family support by way of linkage to community resources.
• Conducts and documents initial assessments of patients’ needs including medical, mental health, substance use and social determinants of health within 60 days of enrollment.
• Provides crisis intervention and health education services as needed.
• Develops individualized patient centered plan of care with documented input and approval from other providers and the patient in compliance with Health Home standards.
• Collaborate with patient and care team to implement plan of care towards achieving goals.
• Coordinates patient services with internal and external service providers through regular care conferencing.
• Documents all patient related encounters and interventions in patient’s chart per established workflow.
• Updates plan of care with outcomes of interventions per established workflow.
• Affords assistance in coordinating care with pharmacies, managed care organizations (MCOs), hospital discharge planning and other members of patient’s care team.
• Completes annual reassessment in accordance with Health Home and State guidelines.
• Prepares for and facilitates team meetings to delegate plan of care tasks to care team members.
• Maintains timely and effective communication with care team regarding all relevant matters pertaining to patient care.
• Reviews providers’ schedules and individual patients’ charts, to assist the care team in coordination of care for current and future visits.
• Uses registry and other care plan information to inform care team members of care plan implementation required for each patient.
• Maintains monitoring of patient’s adherence to their medical appointments.
• Responds to patient’s complaints and concerns according to CHN and Health Home policy guidelines.
• Participates in Quality Assurance (QA) and Quality Initiative (QI) projects.
• Develops knowledge and awareness of available community resources in order to assist patients in achieving plan of care goals and addressing social determinants of health.
• Provides excellent customer service according to CHN guidelines.
• Complies with Employee Health Services.
• Maintains and keeps at all times ALL HIPPA, corporate compliance, and Health Home guidelines.

Knowledge, Skills And Abilities Required

• Proficiency in verbal communication in English.
• Demonstrated ability to work effectively in a team environment.
• Demonstrated problem solving skills in a complex environment.
• Demonstrated effective interpersonal relationship and customer service skills.
• Good organizational and time management skills.
• Good working knowledge of local social service resources or skills to acquire and use this knowledge and information expeditiously.
• Ability to work effectively with people from diverse cultures and diverse socioeconomic situations.
• Basic level of skill with Microsoft Word, Excel and ability to use other computer programs and applications (EMRs, etc) in ways that facilitate disease/care coordination management.

Physical Demands/Working Conditions

• Ability to stand, walk or sit for an extended period of time.
• Ability to hear within normal range.
• Ability to see within normal range.
• Excellent verbal and written communications skills.
• Ability to deal with agitated patients and staff.
• Extended periods of time at a computer.
• Finger and hand dexterity to manipulate objects.
• Extensive travel on public transportation (only bus & train) to and from sites.
• Noise level is moderate.
• Possible exposure to inclement weather when conducting field work.
• Possible exposure to patients with infectious diseases.
• Ability to communicate easily and display a cordial manner towards individuals from a variety of socio-economic, cultural and religious background.